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1  -raAHKLlMl^W^mSHALL- 


Property  of  the 

Lancaster  City  and  County 
Medical  Society 


No 


I  111 

L 


f  I 


\ 


THE 


AMERICAN  JOURNAL 

OF  THE 

MEDICAL  SCIENCES. 


I.  MINIS  HAYS,  A.M.,  M.D. 

NEW  SERIES. 
VOL.  LXXXIX. 


PHILADELPHIA: 
LEA  BEOTHEES  &  CO. 
1885. 


60515 


Entered  according  to  the  Act  of  Congress,  in  the  year  1885,  by 

LEA   BROTHERS    &  CO., 
in  the  Office  of  the  Librarian  of  Congress.    All  rights  reserved. 


PHILADELPHIA : 
COLLINS,  PRINTER, 

705  J ayue  Street. 


TO  READERS  AND  CORRESPONDENTS. 


All  communications  intended  for  insertion  in  the  Original  Department  of  this 
Journal  are  only  received  for  consideration  with  the  distinct  understanding  that 
they  are  sent  for  publication  to  this  Journal  alone,  and  that  abstracts  of  them 
shall  only  appear  elsewhere  subsequently,  and  with  due  credit.  Gentlemen 
favoring  us  with  their  communications  are  considered  to  be  bound  in  honor  to 
a  strict  observance  of  this  understanding. 

Contributors  who  wish  their  articles  to  appear  in  the  next  number  are  requested 
to  forward  them  before  the  1st  of  February. 

Liberal  compensation  is  made  for  all  articles  used.  Extra  copies,  in  pamphlet 
form  with  cover,  will  be  furnished  to  authors  in  lieu  of  compensation,  provided 
the  request  for  them  be  written  on  the  manuscript. 

The  following  works  have  been  received  for  review  :  — 

Zur  Diagnostik  der  Augenkrankheiten  mit  Bezug  auf  Lokalization  von  Cerebro- 
spinalleiden.    Von  Dr.  L.  Grossmann. 

Ein  Neues  Fleischpepton.  Nahrmittel  und  Genussmittel  fur  Kranke  und  Gesunde 
von  Dr.  W.  Kochs.    Mit  7  Tafeln.    Bonn  :  von  Max  Cohen  &  Sohn,  1884. 

Lehrbuch  der  Physiologie  fur  academische  Vorlesungen  und  zum  Selbstudium. 
Regriindet  von  Rud.  Wagner,  fortsjefuhrt  von  Otto  Fqnke,  neue  herausgegeben  von 
Dr.  A.  Gruenhagan,  Prof,  an  der  Univ.  zu  Konigsberg,  etc.  Siebente,  neue  bearbeitete 
Auflage  ;  3te  Lieferung.    Hamburg  und  Leipbis: :  Leopold  Voss,  1884. 

Ueber  die  Verwendung  des  Cocain  zur  Anasthesirung  am  Auge.  Von  Dr.  Karl 
Koller  in  Wien. 

Medico-Chirurgieal  Transactions.  Published  by  the  Royal  Medical  and  Chirurgi- 
cal  Society  of  London.  Second  series.  Vol.  LXVII.  London  :  Longmans,  Green  & 
Co.,  1884. 

Guy's  Hospital  Reports.  Edited  by  Frederick  Taylor,  M.D.,  and  N.  Davies  Col- 
ley,  M.D.,  M.C.    Vol.  XLII.    London  :  J.  &  A.  Churchill,  1884. 

Transactions  of  the  Ophthalmolo°:ical  Society  of  the  United  Kingdom.  Vol.  IV. 
1883-84.    London  :  J.  &  A.  Churchill,  1884. 

Transactions  of  the  Academy  of  Medicine  in  Ireland.  Vol.  II.  Edited  by  William 
Thompson,  M.A.,  F.R.C.S.,  etc.  etc.  Dublin:  Fannin  &  Co.  London:  Bailliere, 
Tindal  &  Cox,  1884. 

Diseases  of  the  Spinal  Cord.  By  Byrom  Bramwell,  M.D.,  F.R.C.P.  (Edin.),  etc. 
Second  edition.    Edinburgh  :  Young  J.  Pentland,  1884. 

Clinical  and  Pathological  Observations  on  Tumors  of  the  Ovary,  Fallopian  Tubes, 
and  Broad  Ligament.  By  Alban  H.  G.  Doran,  F.R.C.S.  London  :  Smith,  Elder  & 
Co.,  1884. 

A  Treatise  on  the  Theory  and  Practice  of  Medicine.  By  John  Syer  Bristowe, 
M.D.  Lond.,  LL.D.  Edin.,  F.R.S.,  F.R.C.P.,  Senior  Physician  to  and  Lecturer  on 
Medicine  at  St.  Thomas's  Hospital.  Fifth  edition.  London  :  Smith,  Elder  &  Co.,  1884. 

Six  Introductory  Lectures  delivered  in  the  Medical  Department  of  Owens  College, 
Manchester,  May,  1884.  By  Dr.  Callingworth,  Dr.  Ashby,  Dr.  Leech,  Dr.  Thor- 
burn,  Mr.  Mould,  and  Dr.  Ransome.  With  a  Preface  by  Professor  Arthur  Gamge, 
M.D.,  Manchester:  J.  G.  Cornish,  1884. 

Discussion  on  Albuminuria,  its  Pathology  and  Clinical  Significance.  Glasgow,  1884. 

Spinal  Deformity  in  Relation  to  Obstetrics.  By  A.  H.  Freeland  Barbour,  M.A., 
M.D.,  F.R.C.P.E.    Edinburgh  and  London  :  W.  &  A.  K.  Johnston. 

Remarks  on  the  Repair  of  Wounds  and  Fractures  in  Aged  Persons.  By  G.  M. 
Humphrey,  M.D.,  F.R.S. 

The  Opthalmoscope  and  Lens.  By  Ole  Bull,  M.D.  Christiana  :  P.  T.  Mailing, 
1884. 

Manual  of  Chemistry.  A  Guide  to  Lectures  and  Laboratory -work  for  Beginners  in 
Chemistry.  A  Text-Book  specially  adapted  for  Students  of  Pharmacy  and  Medicine. 
By  W.  Simon,  Ph.D.,  M.D.    Philadelphia  :  Henry  C.  Lea's  Son  &  Co.,  1884. 

The  Elements  of  Physiological  and  Pathological  Chemistry.  By  T.  Cranstoun 
Charles,  M.D.    Philadelphia  :  Henry  C.  Lea's  Son  &  Co.,  1884. 


8 


TO  READERS  AND  CORRESPONDENTS. 


The  Elements  of  Physiological  Physics  :  an  Outline  of  the  Elementary  Facts,  Prin- 
ciples, and  Methods  of  Physics ;  and  their  Application  in  Physiology.  By  J.  McGregor 
Robertson,  M.A.,  MB.,  CM.    Philadelphia  :  Henry  C.  Lea's  Son  &  Co.,  1884. 

The  Science  and  Art  of  Surgery.  A  Treatise  on  Surgical  Injuries,  Diseases,  and 
Operations.  By  John  Eric  Erichsen,  F.R.S.,  LL.D.,  F.R.C.S.  Eighth  edition.  Re- 
vised and  edited  by  Marcus  Beck,  M.S.  and  M.B.  Lond.,  F.R.C.S.  Vol.  I.  Phila- 
delphia :  Henry  C.  Lea's  Son  &  Co.,  1884. 

Doctiines  of  the  Circulation.  A  History  of  the  Physiological  Opinion  and  Discovery 
in  Regard  to  the  Circulation  of  the  Blood.  By  J.  C.  Dalton,  M.D.  Philadelphia  : 
Henry  C.  Lea's  Son  &  Co.,  1884. 

A  Hand-book  of  Ophthalmic  Science  and  Practice.  By  Henry  Juler,  F.R.C.S. 
Philadelphia  :  Henry  C.  Lea's  Son  &  Co.,  1884. 

The  Principles  and  Practice  of  Gynaecology.  By  Thomas  Addis  Emmet,  M.D., 
LL.D.  Third  edition,  thoroughly  revised.  Philadelphia  :  Henry  C.  Lea's  Son  &  Co., 
1884. 

Elements  of  Surgical  Diagnosis.  By  A.  Pierce  Gould,  M.S.,  M.B.  Lond.,  F.R.C.S. 
Eng.    Philadelphia  :  Henry  C.  Lea's  Son  &  Co.,  1884. 

Intestinal  Obstruction  :  Its  Varieties,  with  their  Pathology,  Diagnosis,  and  Treat- 
ment. The  Jacksonian  Prize  Essay  of  the  Royal  College  of  Surgeons,  England,  1883. 
By  Frederick  Treves,  F.R.C.S.    Philadelphia  :  Henry  C.  Lea's  Son  &  Co.,  1884. 

The  Elements  of  Pathology.  By  Edward  Rindfleisch,  M.D.,  Professor  of  Patho- 
logical Anatomy  in  the  University  of  W'urtzburg.  Translated  from  the  first  German 
edition,  by  Wm.  H.  Mercur,  M.D.  Revised  by  James  Tyson,  M.D.,  etc.  Philadelphia: 
P.  Blakiston,  Son  &  Co.,  1884. 

Surgical  Delusions  and  Follies.  A  Revision  of  the  Address  in  Surgery  for  1884  of 
the  Medical  Society  of  the  State  of  Pennsylvania.  By  John  B.  Roberts,  A.M.,  M.D. 
Philadelphia  :  P.  Blakiston,  Son  &  Co.,  1884. 

The  Physician's  Visiting  List  for  1885.  Philadelphia  :  P.  Blakiston,  Son  &  Co. 

Lectures  on  some  Important  Points  Connected  with  the  Surgery  of  the  Urinary  Or- 
gan. By  Sir  Henry  Thompson,  F.R.C.S.,  M.B.  Philadelphia  :  P.  Blakiston,  Son  & 
Co.,  1884. 

On  Diseases  of  the  Rectum  and  Anus,  including  a  Portion  of  the  Jacksonian  Prize 
Essay  on  Cancer.  By  Harrison  Cripps,  F.R.C.S.  Philadelphia  :  P.  Blakiston,  Son 
&  Co.,  1884. 

Holden's  Anatomy.  A  Manual  of  Dissection  of  the  Human  Body.  By  Luther 
Holden.  Fifth  edition.  Edited  by  John  Langton.  Philadelphia  :  P.  Blakiston, 
Son  &  Co.,  1885. 

Lectures  on  the  Principles  of  Surgery.  Delivered  at  Bellevue  Hospital  Medical  Col- 
lege. By  W.  H.  Van  Buren,  M.D.,  LL.D.  Edited  by  Lewis  A.  Stimson,  M.D. 
New  York  :  D.  Appleton  &  Co.,  1884. 

Myths  in  Medicine  and  Old-time  Doctors.  By  Alfred  C.  Garratt,  M.D.,  New 
York  and  London  :  G.  P.  Putnam's  Sons,  1884. 

A  Text-Book  of  Practical  Medicine,  designed  for  the  Use  of  Students  and  Practi- 
tioners of  Medicine.  By  Alfred  L.  Loomis,  M.D.,  LL.D.  New  York  :  Wm.  Wood 
&  Co.,  1884. 

Medical  Record  Visiting  List,  or  Physician's  Diary  for  1885.  New  York  :  Wm. 
Wood  &  Co. 

A  Treatise  on  the  Hemorrhoidal  Disease,  Giving  its  History,  Nature,  Causes,  Path- 
ology, Diagnosis,  and  Treatment.  By  William  Bodenhamer,  A.M.,  M.D.  New 
York  :  Wm.  Wood  &  Co.,  1884. 

A  Practical  Treatise  on  Diseases  of  the  Ear,  including  a  Sketch  of  Aural  Anatomy 
and  Physiology.  By  D.  B.  St.  John  Roosa,  M.D.,  LL.D.  New  York:  Wm.  Wood  & 
Co.,  1884. 

A  Practical  Treatise  on  Massage.  By  Douglas  Graham,  M.D.  New  York ;  Wm. 
Wood  &  Co.,  1884. 

An  Aid  to  Materia  Medica.  By  Robert  H.  M.  Dawbarn,  M.D.  New  York  :  J.  H. 
Vail  &  Co.,  1884. 

The  Lock-Jaw  of  Infants  (Trismus  Nascentium),  or  Nine  Day  Fits,  Crying  Spasms, 
etc.  Its  History,  Cause,  Prevention,  and  Cure.  By  J.  F.  Hartigan,  M.D.,  of  Wash- 
ington, D.  C.    New  York  :  Bermingham  &  Co.,  1884. 

Diseases  of  the  Nose.  By  Clinton  Wagner,  M.D.  New  York  :  Bermingham  &  Co., 
1884. 

Lectures  on  Diseases  of  the  Rectum.  By  J.  Williston  Wright,  M.D.  New  York  : 
Bermingham  &  Co.  1884. 

The  Principles  and  Practice  of  Midwifery,  with  some  of  the  Diseases  of  Women. 
By  Alexander  Milne,  M.D.   Second  edition.  New  York:  Bermingham  &  Co.,  1884. 

Medical  Diagnosis.  A  Manual  of  Clinical  Methods.  By  J.  Graham  Browne,  M.D., 
F.R.C.P.  (Edinb.).  Second  edition.  New  York  :  Bermingham  &  Co.,  1884. 

A  Manual  of  Dermatology.  By  A.  R.  Robinson,  M.B..  L.R.C.P.  &  S.  Edinb.,  etc. 
New  York  :  Bermingham  &  Co.,  1884. 


TO  READERS  AND  CORRESPONDENTS. 


9 


Index-Catalogue  of  the  Library  of  the  Surgeon-General's  Office,  United  States  Army. 
Authors  and  Subjects.  Vol.  V.  Flaccus — Hearth.  Washington  :  Government  Print- 
ing Office,  1884. 

Cases  of  Interest.    By  Prof.  W.  H.  Carmalt,  M.D.,  of  New  Haven. 

Lectures  on  the  Principles  and  Practice  of  Medicine.  By  Nathan  Smith  Davis, 
A.M.,  M.D.,  LL.D.    Chicago  :  Jansen,  McClurg  &  Co.,  1884. 

Medical  Rhymes.  Selected  and  compiled  by  Hugo  Erichsen,  M.D.,  etc.,  with  an 
introduction  by  Prof.  Willis  P.  King,  M.D.  St.  Louis,  Chicago,  and  Atlanta  :  J.  H. 
Chambers  &  Co.,  1884. 

Comparative  Physiology  and  Psychology.  By  S.  V.  Clevenger,  Md.  Chicago  : 
Jansen,  McClurg  &  Co.,  1885. 

The  Basic  Pathology  and  Specific  Treatment  of  Diphtheria,  Typhoid,  Zymotic,  Septic, 
Scorbutic,  and  Putrescent  Diseases  generally.  By  George  J.  Ziegler,  M.D.  Phila- 
delphia :  George  J.  Ziegler,  1884. 

Contributions  to  the  Anatomy  and  Pathology  of  the  Nervous  System.  Singular 
Case  of  Vertebral  Disease.    By  Richard  Mollenhauer,  M.D. 

One  Aspect  of  the  Subject  of  Medical  Examination  as  set  forth  in  the  North  Caro- 
lina Board  of  Medical  Examiners.    North  Carolina  Board  of  Health. 

Listerism  in  Obstetrics.  Shall  we  adopt  it  in  General  Practice  ?  By  W.  Sharp,  M.D. , 
Volcano,  W.  Va. 

Report  on  a  Case  of  Acute  Mania.  Treatment  in  the  Acute  Stage  by  Exercise  and 
Feeding.    Recovery.    By  Alex.  Nellis,  Jr.  M.D.,  Williard,  N.  Y. 

The  Ambulance  Movement  in  Scotland.  By  James  Whitson,  M.D.,  F.F.P.  and 
S.G.,  F.R.M.S.,  Glasgow. 

Successful  GCsophagotomy  for  the  Removal  of  Foreign  Bodies.  By  LeRoy  McLean, 
M.D.,  Troy,  N.  Y. 

The  Influence  of  Climate  on  the  Treatment  of  Chronic  Catarrh  of  the  Middle  Ear. 
By  John  F.  Fulton,  M.D.,  Ph.D.,  of  Chicago. 

Madness  and  Crime.    By  Clark  Bell,  Esq.,  of  New  York, 

Explanation  of  the  Pathology  and  Therapeutics  of  the  Diseases  of  the  Nerve  Centres, 
especially  Epilepsy.    By  J.  M.  F.  Gaston,  M.D.,  of  Atlanta,  Ga. 

Case  of  Chronic  Purulent  Inflammation  of  the  Middle  Ear  giving  Rise  to  Intracranial 
Disease — Double  Optic  Neuritis — Recovery.    By  Dr.  John  C^  Fulton,  St.  Paul,  Minn. 

On  Oxygen  as  a  Remedial  Agent.    By  Samuel  S.  Williams,  A.M.,  M.D. 

Club-Foot.    Is  Excision  of  the  Tarsus  necessary  in  Children  ?    By  De  Forest  Wil- 

LARD,  M.D. 

Force  v.  Work.  Some  Practical  Remarks  on  Dietetics  on  Disease.  By  William 
Pepper,  M.D.,  LL.D. 

The  Dry  Treatment  of  Chronic  Suppurative  Inflammation  of  the  Middle  Ear.  By 
Charles  J.  Lundy,  A.M.,  M.D. 

Diphtheria  Spread  by  Adults.    By  A.  Jacobi,  M.D. 

The  Rational  Treatment  of  Chorea.  By  John  Van  Bibber,  M.D.,  of  Baltimore,  Md. 

Description  of  the  Physiological  Laboratory,  Harvard  Medical  School,  Boston,  1884. 

Prostatic  Hydropathy  and  Urinary  Obstructions.  Its  Treatment  without  Catheter- 
ization.   By  A.  B.  Palmer,  M.D.,  LL.D.,  Ann  Harbor. 

The  Plaster  of  Paris  Dressing  in  the  Treatment  of  Fractures.  By  W.  O'Daniel,  of 
Georgia. 

Muriate  of  Cocaine  in  Ophthalmic  Surgery.    By  C.  J.  Lundy,  A.M.,  M.D. 

Transactions  of  the  American  Otolo^ical  Society,  Seventeenth  Annual  Meeting. 
Vol.  III.    Part  3.    New  Bedford,  Mass.,  1884. 

Transactions  of  the  Medical  Association  of  the  State  of  Alabama.  The  Report  of 
the  Board  of  Health.    Thirty-sixth  Annual  Session. 

Transactions  of  the  Indiana  State  Medical  Society,  1884.    Indianapolis,  1884. 

Transactions  of  the  Medical  Society  of  the  State  of  New  York  for  the  year  1884. 

Sanitary  and  Statistical  Report  of  the  Surgeon-General  of  the  Navy  for  the  year  1882. 
Washington  :  Government  Printing  Office,  1884. 

Forty-second  Report  to  the  Legislature  of  Massachusetts,  Relating  to  the  Registry 
and  Return  of  Births,  Marriages,  and  Deaths  in  the  Commonwealth,  for  the  year  end- 
ing December  31,  1883.  Together  with  a  Report  relating  to  the  Returns  of  the  Libels 
for  Divorce,  for  the  year  1883.  With  editorial  Remarks.  By  Frank  Wells,  M.D., 
Boston,  1884. 

Annual  Report  of  the  National  Board  of  Health,  1883. '  Washington  :  Government 
Printing  Office,  1884. 

Annual  Report  of  the  Surgeon-General  of  the  United  States  Army,  1884. 

Fourth  Annual  Report  of  the  State  Board  of  Health  of  New  York.   Albany,  1884. 


10 


TO  READERS  AND  CORRESPONDENTS. 


The  following  Journals  have  been  received  in  exchange : — 

r«X»jvo?.  Bibliothek  for  Lseger.  Kronika  Lekarska.  Annali  Universali  di  Medecina 
e  Chirurgia.  Archivio  di  Orthopedia.  El  Ensayo  Medico.  Gazzetta  degli  Ospitali. 
Nordiskt  Medicinskt  Arkiv.  Upsala  Lakareforenings  Fordhandlingar.  Giorn.  Ital. 
Mai.  Ven.  Revista  Internaz.  di  Med.  e  Chir.  Commentario  Clin.  Mai.  Genito-Urin. 
Boletin  de  Ciencias  Medicas.  L'Imparziale.  Lo  Sperimentale.  Rivisit.  Veneta  di  Sci. 
Med.  O  Correio  Medico  de  Lisboa.  Croniea  Medico-Quirurgica  dela  Habana.  Uniao 
Medico.  La  Union  Medica,  Caracas.  Allgemeine  Wiener  med.  Zeitung.  Berliner 
klinische  Wochenschriffc.  Centralblatt  fur  Chirurgie.  Centralblatt  fur  Gynakologie. 
Centralblatt  fiir  klinische  Medicin.  Centralblatt  fur  die  medicinischen  Wissenschaften. 
Centralblatt  fiir  die  gesammte  Therapie.  Deutsches  Archiv  fiir  klinische  Medicin. 
Deutsche  medicinische  Wochenschrift.  Medicinisch  -  Chirurgisches  Centralblatt. 
Medizinische  Jahrbueher.  Monatsheft  fiir  prak.  Dermatol.  Wiener  med.  Presse. 
Wiener  Klinik.  Zeits.  fur  physiol.  Chemie.  Annales  de  Dermatol ogie  et  de  Syphili- 
graphie.  Annales  de  G3rnecologie.  Annales  des  Maladies  Genito-Urinaires.  Annales 
des  Mai.  de  l'Oreille,  etc.  Archives  de  Med.  et  Pharm.  Militaires.  Archives  de  Toxi- 
cologic Archives  Generales  de  Medecine.  Bulletin  Generale  de  Therapeutique. 
Gazette  Hebdomadaire.  Gazette  Medicale  de  Nantes.  Gazette  Medicale  de  Paris. 
Gazette  Medicale  de  l'Orient.  Gazette  Hebdom.  de  Montpellier.  Journal  de  Medecine 
de  Paris.  L'Abeille  Medicale.  L'Encephale.  Le  Progres  Medical.  L'Union  Medicale. 
Revue  de  Chirurgie.  Revue  de  Medecine.  Revue^  de  Therapeutique.  Revue  des 
Sciences  Medicales.  Revue  Medicale  Francaise  et  Etrangere.  Revue  Mensuelle  de 
Laryngologie.  Union  Medicale  et  Scientiflque  du  Nord-Est.  The  Asclepiad.  Brain. 
Braithwaite's  Retrospect.  British  Medical  Journal.  Dublin  Journal  of  Medical 
Science.  Edinburgh  Medical  Journal.  Glasgow  Medical  Journal.  Journal  of  Physio- 
logy. Journal  of  Psychological  Medicine.  Lancet.  Liverpool  Medico-Chirurgical 
Journal.  London  Medical  Record.  Medical  Times  and  Gazette.  Midland  Medical 
Miscellany.  Ophthalmic  Review.  Practitioner.  Proc.  N.  W.  Provinces  and  Oudh 
Branch.  Australian  Medical  Journal.  Indian  Medical  Gazette.  Bristol  Medico- 
Chirurgical  Journal. 

Alienist  and  Neurologist.  American  Druggist.  American  Journal  of  Insanity. 
American  Journal  of  Neurology  and  Psychiatry.  American  Journal  of  Obstetrics. 
American  Journal  of  Pharmacj*.  American  Journal  of  Science.  American  Journal 
of  Dental  Science.  American  Medical  Digest.  American  Practitioner.  Analectic. 
Archives  of  Medicine.  Archives  of  Ophthalmolog}*.  Archives  of  Otology.  Ar- 
chives of  Pediatrics.  Atlanta  Medical  and  Surgical  Journal.  Boston  Medical  and 
Surgical  Journal.  Boston  Journal  of  Chemistry.  Buffalo  Medical  and  Surgical 
Journal.  Chicago  Medical  Journal  and  Examiner.  Cincinnati  Lancet  and  Clinic. 
Cincinnati  Medical  News.  College  and  Clinical  Record.  Columbus  Medical  Journal. 
Dental  Cosmos.  Denver  Medical  Times.  Detroit  Lancet.  Druggists'  Circular. 
Ephemeris  of  Materia  Medica,  Pharmacy,  and  Therapeutics.  Fort  Wayne  Journal  of 
Medical  Sciences.  Iowa  State  Medical  Reporter.  Journal  of  the  American  Medical 
Association.  -  Journal  of  Cutaneous  and  Venereal  Diseases.  Journal  of  the  Franklin 
Institute.  Journal  of  Nervous  and  Mental  Diseases.  Independent  Practitioner. 
Kansas  City  Medical  Record.  Kansas  Medical  Index.  Louisville  Medical  News.  Mary- 
land Medical  Journal.  Medical  Age.  Medical  Annals.  Medical  Herald.  Medical 
News.  Medical  and  Surgical  Reporter.  Medical  Record.  Mississippi  Valley  Medical 
Monthly.  Nashville  Journal  of  Medicine  and  Surgery.  New  Medical  Era  and 
Sanitarian.  New  Orleans  Medical  and  Surgical  Journal.  New  York  Medical  Journal. 
North  Carolina  Medical  Journal.  Obstetric  Gazette.  Pacific  Medical  and  Surgical 
Journal.  Popular  Science  Monthly.  Philadelphia  Medical  Times.  Rocky  Mountain 
Medical  Times.  Physician  and  Surgeon.  San  Francisco  Western  Lancet.  Sanita- 
rian. Sanitary  Engineer.  Sanitary  News.  Pharmaceutical  Record.  Quarterly 
Journal  of  Inebriety.  Southern  Practitioner.  St.  Louis  Courier  of  Medicine.  St. 
Louis  Medical  and  Surgical  Journal.  Texas  Courier  of  Medicine.  Therapeutic  Ga- 
zette. The  Polyclinic.  Virginia  Medical  Monthly.  Weekly  Medical  Review.  Western 
Medical  Reporter.  Canadian  Practitioner.  Canada  Lancet.  Canada  Medical  Record. 
Canada  Medical  and  Surgical  Journal.    L'Union  Medicale  du  Canada. 


Communications  intended  for  publication,  and  books  for  review,  should  be  sent 
free  of  expense,  directed  to  I.  Minis  Hays,  M.D. ,  Editor  of  the  American  Journal  of  the 
Medical  Sciences,  care  of  Lea  Brothers  &  Co.,  Philadelphia.  Parcels  directed  as 
above, and  (carriage  paid)  under  cover,  to  Messrs.  Nimmo  &  Bain,  Booksellers,  No.  14 
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CONTENTS 


OF 


THE  AMI HI  CAN  JOURNAL 

OF 

THE  MEDICAL  SCIENCES. 
NO.  CLXXVII.    NEW  SERIES. 
JANUARY,  1885. 


ORIGINAL  COMMUNICATIONS. 
MEMOIRS  AND  CASES. 

ART.  PAGE 

I.  Injection  of  Finely  Powdered  Inorganic  Material  into  the  Abdominal 
Cavity  of  Rabbits  does  not  induce  Tuberculosis.  An  Experimental  Re- 
search. By  George  M.  Sternberg,  Major  and  Surgeon,  U.  S.  A.,  with 
Pathological  Notes  by  AVm.  T.  Councilman,  M.D.,  Associate  in  Pathology, 
Johns  Hopk  ins  University  17 

II.  A  Contribution  to  Jacksonian  Epilepsv  and  the  Situation  of  the  Leg 
Centre.  By  William  Osier,  M.D.,  F.R.'C.P.  Lond.,  Professor  of  Clini- 
cal Medicine  in  the  University  of  Pennsylvania      .        .       .       .  .31 

III.  Intermediate  Hospitals  for  the  Treatment  of  Acute  Mental  Diseases. 

By  John  Van  Bibber,  M.D.,  of  Baltimore  38 

IV.  An  Obscure  Case  of  Popliteal  Aneurism  which  simulated  Sarcoma.  By 
Francis  J.  Shepherd,  M.D.,  Professor  of  Anatomy  McGill  University  ; 
Surgeon  to  the  Montreal  General  Hospital      ......  52 

V.  Double  Infantile  Spastic  Hemiplegia,  with  the  Report  of  a  Case.  By 
Sarah  J.  McNutt,  M.D.,  Lecturer  on  Children's  Diseases  in  the  New 
York  Post- Graduate  Medical  College,  and  Instructor  in  Gynecology  in 
the  Woman's  Medical  College  of  the  New  York  Infirmary     .        .  .58 

VI.  Note  on  a  Peculiar  Form  of  Pulmonary  Congestion,  not  generally  known, 
and  Terminating  in  Sudden  Death  ;  together  with  a  Plea  for  Cardiac  As- 
piration. By  A.  H.  P.  Leuf,  M.D.,  Pathologist  to  St.  Mary's  General 
Hospital,  Brooklyn,  N.  Y.,  and  Secretary  of  the  Brooklyn  Pathological 
Society,  etc.  ............  79 

VII.  Case  of  Dermatitis  Herpetiformis  caused  by  Nervous  Shock.  By  Louis 
A.  Duhring,  M.D.,  Professor  of  Skin  Diseases  in  the  University  of  Penn- 
sylvania  .94 

VIII.  A  Correlation  Theory  of  Color-perception.  By  Charles  A.  Oliver, 
A.M.,  M.D  ,  one  of  the  Ophthalmic  and  Aural  Surgeons  to  St.  Mary's 
Hospital,  Philadelphia   .       .       .       .  .       .        .       .  .98 


12  CONTENTS. 

ART.  PAGE 

IX.  A  Case  of  Lodgment  of  a  Breech-Pin  in  the  Brain ;  Removal  on  the 
Second  day;  Recovery.  By  G.  W.  H.  Kemper,  M.D.,  of  Mimcie, 
Indiana        .   .  j  128. 

X.  Introspective  Insanity  (Folie  dn  doute ;  Grlibelsucht).  By  Allan  Mc- 
Lane  Hamilton,  M.D.,  one  of  the  Consulting  Physicians  to  the  New  York 
City  Insane  Asylum,  etc.       .       .       .       .        .       .       .       .  .130 

XL  Poliomyelitis  Anterior  in  Adults.  By  Gustavus  Eliot,  A.M.,  M.D., 
of  New  Haven,  Connecticut  .........  138 

XII.  Observations  on  the  Regeneration  of  the  Vagus  and  Hypoglossal 
Nerves.  By  Edward  T.  Reichert,  M.D.,  Demonstrator  of  Experimental 
Physiology  and  Experimental  Therapeutics  in  the  University  of  Pennsyl- 
vania  146 

XIII.  Erysipelas  as  a  Complication  of  Pregnancy  and  Labor  ;  with  a  Report 
of  a  Case  of  Herniotomy,  performed  on  a  Patient  suffering  from  Erysi- 
pelas. By  G.  H.  Balleray,  M.D.,  Surgeon  to  St.  Joseph's  Hospital,  and 
the  Ladies'  Hospital,  Paterson,  N.  J.,  and  to  the  Woman's  Hospital, 
Newark,  N.J  160 

XIV.  Psoriasis — Verruca — Epithelioma;  a  Sequence.  By  James  C.  White, 
M.D.,  Professor  of  Dermatology  in  Harvard  University  .       .       .       .  163 

XV.  A  Case  of  Unilateral  Spasm  of  the  Tongue.  By  Edmund  C.  Wendt, 
M.D.,  of  New  York  173 


REVIEWS. 

XVI.  Recent  Works  on  Practice. 

1.  Lectures  on  the  Principles  and  Practice  of  Medicine,  delivered  in  Chi- 

cago Medical  College.  By  Nathan  Smith  Davis,  A.M.,  M.D.,  LL.D., 
Dean  of  the  Faculty,  and  Professor  of  Principles  and  Practice  of 
Medicine.  8vo.  pp.  896.  Chicago:  Jansen,  McClurg  &  Co.,  1884. 

2.  A  Text-book  of  Practical  Medicine,  designed  for  the  use  of  Students 

and  Practitioners  of  Medicine.  By  Alfred  L.  Loomis,  M.D.,  LL.D., 
Professor  of  Pathology  and  Practical  Medicine  in  the  Medical  Depart- 
ment of  the  University  of  the  City  of  New  York.  8vo.  pp.  1102. 
211  Illustrations.    New  York:  Wm.  Wood  &  Co.,  1884. 

3.  A  Treatise  on  the  Theory  and  Practice  of  Medicine.    By  John  Syer 

Bristowe,  M.D.,  LL.D.,  F.R.S.,  Fellow  of  the  Royal  College  of 
Physicians ;  Senior  Physician  to,  and  Lecturer  on  Medicine  at  St. 
Thomas's  Hospital,  London.  8vo.  pp.  1240.  Fifth  edition.  Lon- 
don:  Smith,  Elder  &  Co.,  1884   .175 

XVn.  Malaria  and  Malarial  Diseases.  By  George  M.  Sternberg,  M.D., 
F.R.M.S.,  Major  and  Surgeon  U.  S.  Army;  Member  of  the  Biological 
Society  of  Washington  ;  late  Member  of  the  Havana  Yellow  Fever  Com- 
mission of  the  National  Board  of  Health  ;  Corresponding  Member  of  the 
Epidemiological  Society  of  London,  etc.  8vo.  pp.  329.  New  York : 
William  Wood  &  Co.,  1884    182 

XVIII.  Clinical  and  Pathological  Observations  on  Tumors  of  the  Ovary, 
Fallopian  Tube,  and  Broad  Ligament.  By  Alban  H.  G.  Doran,  F.R.C.S., 
Assistant  Surgeon  to  the  Samaritan  Free  Hospital,  formerly  Anatomical 
and  Pathological  Assistant  to  the  Museum  of  the  Royal  College  of  Sur- 
geons of  England.  With  thirty  illustrations.  8vo.  pp.  189.  London, 
1884      .   186 


CONTENTS. 


13 


ART.  PAGE 

XIX.  The  Principles  of  Ventilation  and  Heating,  and  their  Practical  Appli- 
cation. By  John  S.  Billings,  M.D.,  LL.D.  (Edinb.),  Surgeon  U.  S. 
Army.  8vo.  pp.  216.  Seventy-two  illustrations.  New  York:  The  Sani- 
tary Engineer,  1884    190 

XX.  Diseases  of  the  Heart  and  Thoracic  Aorta.  By  Byrom  Brarawell, 
M.D.,  F.R.C.P.E.,  Lecturer  on  the  Principles  and  Practice  of  Medicine, 
and  on  Practical  Medicine  and  Medical  Diagnosis  in  the  Extra- Academi- 
cal School  of  Medicine,.  Edinburgh,  Pathologist  to  the  Edinburgh  Royal 
Infirmary,  etc.  etc.    8vo.  pp.  782,  with  317  illustrations.    New  York: 

D.  Appleton  &  Co.,  1884    196 

XXI.  On  Tumors  of  the  Bladder,  their  Nature,  Symptoms,  and  Surgical 
Treatment.  By  Sir  Henry  Thompson,  F.R.C.S.,  M.B.  Lond.,  Surgeon 
Extraordinary  to  H.  M.  the  King  of  the  Belgians,  Professor  of  Surgery 
and  Pathology  to  the  Royal  College  of  Surgeons.  Consulting  Surgeon  to 
University  College  Hospital,  etc.  8vo.  pp.  111.  Philadelphia:  P.  Blaki- 
ston,  Son  &  Co.,  1884    .       .       .   202 

XXII.  Insanity  Considered  in  its  Medico-Legal  Relations.  By  T.  R. 
Buckham,  A.M.,  M.D.    8vo.  pp.  265.    Philadelphia:  J.  B.  Lippincott 

&  Co.,  1883  .   206 

XXIII.  Osteotomy  and  Osteoclasis  for  Deformities  of  the  Lower  Extremi- 
ties. By  Charles  T.  Poore,  M.D.,  Surgeon  to  St.  Mary's  Free  Hospital 
for  Children,  New  York  ;  Member  of  the  New  York  Surgical  Society,  etc. 
8vo.  pp.  183.    New  York:  D.  Appleton  &  Co.,  1884    ....  210 

XXIV.  Recent  Works  on  Albuminuria  and  the  Testing  of  Urine. 

1.  On  the  Various  Modes  of  Testing  for  Albumen  and  Sugar  in  the  Urine. 

Two  Lectures  by  George  Johnson,  M.D.    London,  1884. 

2.  On  Bedside  Urine  Testing,  including  Quantitative  Albumen  and  Sugar. 

By  George  Oliver,  M.D.    2d  edition.    London,  1884. 

3.  Discussion  on  Albuminuria,  its  Pathology  and  Clinical  Significance, 

before  the  Glasgow  Pathological  and  Clinical  Society.  Reprinted 
from  the  Glasgow  Medical  Journal.    Glasgow,  1884        ...  213 

XXV.  The  Diagnosis  of  Diseases  of  the  Spinal  Cord.  By  W.  R.  Gowers, 
M.D.,  F.R.C.P.,  Assistant  Professor  of  Clinical  Medicine  in  University 
College,  Physician  to  University  College  Hospital,  and  to  the  National 
Hospital  for  Paralyzed  and  Epileptics.  Third  edition,  pp.  92.  Philadel- 
phia :  P.  Blakiston,  Son  &  Co.,  1884    218 

XXVI.  The  National  Dispensatory :  Containing  the  Natural  History, 
Chemistry,  Pharmacy,  Actions  and  Uses  of  Medicines,  including  those 
recognized  in  the  Pharmacopoeias  of  the  United  States,  Great  Britain, 
and  Germany,  with  numerous  references  to  the  French  Codex.  By  Alfred 
Stille,  M.D.,  LL.D.,  Professor  Emeritus  of  the  Theory  and  Practice  of 
Medicine  and  of  Clinical  Medicine  in  the  University  of  Pennsylvania ; 
and  John  M.  Maisch,  Phar.  D.,  Professor  of  Materia  Medica  and  Botany 
in  the  Philadelphia  College  of  Pharmacy.  Third  edition,  thoroughly  re- 
vised, with  numerous  additions.  With  three  hundred  and  eleven  illustra- 
tions.   Royal  8vo.  pp.  xvi.  1755.    Philadelphia:  Henry  C.  Lea's  Son  & 

.  Co.,  1884      .        .        .  .       .  219 

XXVII.  Traite  des  Fievres  Bilieuses  et  Typhiques  des  Pays  Chauds. 
Par  le  Drv  A.  Cbrre,  Medecin  de  Ire  Classe  de  la  Marine ;  Professeur 
Agrege  a.  Ecole  de  Medecine  Navale  de  Brest.  Avec  35  Traces  de  Tem- 
perature dans  le  text.    8vo.  pp.567.    Paris:  Octave  Doin,  1883. 

A  Treatise  on  the  Fevers  of  Hot  Climates.    By  Dr.  A.  Corre    .       .       .  221 

XXVIII.  On  the  Pathology  and  Treatment  of  Gonorrhoea.  By  J.  L. 
Milton,  Senior  Surgeon  to  St.  John's  Hospital  for  Diseases  of  the  Skin, 
London.  Fifth  edition.  8vo.  pp.  viii.  306.  New  York :  William 
Wood  &  Co.,  1884   .'     .       .  .224 


14 


CONTENTS. 


ART.  PAGE 

XXIX.  Recherches  cliniques  et  therapeutiques  sur  l'Epilepsie,  l'Hysterie 
et  l'Idiotie,  compte  rendu  du  service  des  epileptiques  et  des  enfants  idiots 
et  arrieres  de  Bice'tre  pendant  l'ann6e  1881,  par  Bourneville,  Medecin 
de  Bicetre.  Bonnaire  (E.)  et  Wullamie,  internes  da  service.  Paris  : 
Aux  Bureaux  du  Progres  Medical,  1882. 

Recherches  cliniques  et  therapeutiques  sur  l'Epilepsie,  l'Hysterie  et  l'Idiotie, 
et  arrieres  pendant  l'ann6e  1883,  par  Bourneville,  Medecin  de  Biegtre. 
Bonnaire,  Bontier  Leflaive,  internes  du  service  :  P.  Brecin  et  Seglas, 
Docteurs  en  M6decine.  Volume  iv.  avec  8  figures  et  deux  planches. 
Paris:  Aux  Bureaux  du  Progres  Medical,  1884    226 

XXX.  A  System  of  Human  Anatomy,  including  its  Medical  and  Surgical 
Relations.  By  Harrison  Allen,  M.D.,  Professor  of  Physiology  in  the 
University  of  Pennsylvania,  etc.  etc.  Section  V.  Nervous  System. 
Section  VI.  Organs  of  Sense,  of  Digestion,  and  Genito-Urinary  Organs. 
4to.  pp.  xv.  582-812.    Philadelphia:  Henry  C.  Lea's  Son  &  "Co.,  1883  228 

XXXI.  Index-catalogue  of  the  Library  of  the  Surgeon-General's  Office, 
United  States  Army.  Authors  and  Subjects.  Vol.  V.  Flaccus — Hearth. 
4to.  pp.  [ii.]  1055.    Government  Printing  Office,  Washington,  1884      .  230 

XXXII.  Clinical  Chemistry.  By  Charles  Henry  Ralfe,  M.A.,  M.D. 
Cantab.,  Fellow  of  the  Royal  College  of  Physicians,  London,  Assistant 
Physician  at  the  London  Hospital,  etc.  16mo.  pp.  308.  Philadelphia: 
Henry  C.  Lea's  Son  &  Co.,  1884. 

The  Elements  of  Physiological  and  Pathological  Chemistry.  By  T.  Crans- 
toun  Charles,  M.I).,  Fellow  of  the  Chemical  Society  and  Royal  Medical, 
Chirurgical,  and  Pathological  Societies  ;  Demonstrator  of  Physiology  and 
Physiological  Chemistry,  St.  Thomas's  Hospital  Medical  School,  etc. 
Large  8vo.  pp.  463.    Philadelphia  :  Henry  C.  Lea's  Son's  &  Co.,  1884  .  231 

XXXIII.  The  Elements  of  Pathology.  By  Edward  Rindfleisch,  M.D., 
Professor  of  Pathological  Anatomy  in  the  University  of  Wiirzburg.  Trans- 
lated from  the  first  German  edition,  by  Wm.  H.  Mercur,  M.D.  (Univer- 
sity of  Pennsylvania).  Revised  by  James  Tyson,  M.D.,  Professor  of 
General  Pathology  and  Morbid  Anatomy  in  the  University  of  Pennsyl- 
vania, etc.  etc.  12mo.  pp.  263.  Philadelphia:  P.  Blakiston,  Son  &  Co., 
1884    '  234 

XXXIV.  Ueber  Musikalische  Herzgerausche.  Nebst  Bemerkungen  liber 
die  Entstehung  Pseudokardialen  Ger'ausche.  Von  Dr.  Ottomar  Rosen- 
bach,  Privat-dozent  an  der  Universitat  Breslau.  8vo.  pp.  22.  Wien, 
1884. 

Musical  Heart  Murmurs,  with  Remarks  on  the  Occurrence  of  Pseudo-Cardial 
Murmurs.    By  Dr.  Ottomar  Rosenbach  .       .  .        .       .  .235 

XXXV.  Bacteria.  By  Dr.  Antoine  Magnin  and  George  M.  Sternberg, 
M.D.,  F.R.M.S.  8vo.  pp.  xviii.,  494.  New  York :  William  Wood  & 
Co.,  1884    238 

XXXVI.  Diseases  of  the  Brain  and  Spinal  Cord,  a  Guide  to  their  Pathology, 
Diagnosis,  and  Treatment,  with  an  Anatomical  and  Physiological  Intro- 
duction. By  David  Drummond,  M.A.,  M.D.,  Physician  and  Pathologist 
to  the  Newcastle-upon-Tyne  Infirmary,  Joint  Lecturer  on  Pathology  in 
the  University  of  Durham  College  of  Medicine.  8vo.  pp.  374.  51  illus- 
trations.   London:  Henry  Kimpton,  1883     ......  240 

XXXVII.  An  Experimental  Investigation  of  the  Physiological  Action  of 
Saline  Cathartics.  By  Matthew  Hay,  M.D.  Edin.,  Professor  of  Medical 
Jurisprudence  and  Medical  Logic  in  the  University  of  Aberdeen,  formerly 
Assistant  to  the  Professor  of  Materia  Medica  in  the  University  of  Edin- 
burgh. With  woodcuts  and  lithograph.  8vo.  pp.  201.  Edinburgh:  Mac- 
lachlin  &  Stewart.    London:   Simpkin  Marshall  &  Co.,  1884  .       .       .  241 


CONTENTS. 


15 


ART.  PAGE 

XXXVIII.  Recent  Works  on  Ophthalmology. 

1.  The  Refraction  of  the  Eye.    A  Manual  for  Students.    By  Gustavus 

Hartridge,  F.R.C.S.,  Assistant  Surgeon  to  the  Royal  Westminster 
Ophthalmic  Hospital.  8vo.  pp.  204.  London  :  J.  &  A.  Churchill, 
1884. 

2.  A  Treatise  on  Ophthalmology  for  the  General  Practitioner.  By  Adolph 

Alt,  M.D.    8vo.  pp.  2441.    St.  Louis:  J.  H.  Chambers  &  Co.,  1884 

3.  The  General  Practitioner's  Guide  to  Diseases  and  Injuries  of  the  Eve 

and  Eyelids.  By  Louis  H.  Tosswill,  B.A.,  M.B.  Cantab.,  M.R.C.S., 
Surgeon  to  the  West  of  England  Eye  Infirmary  at  Exeter.  8vo.  pp. 
147.    London:  J.  &  A.  Churchill,  *1884    242 

XXXIX.  Elements  of  Practical  Medicine.  By  Alfred  H.  Carter,  M.D. 
Lond.,  Member  of  the  Royal  College  of  Physicians,  London,  Physician 
to  the  Queen's  Hospital,  Birmingham,  Assistant  Physician  to  the  Child- 
ren's Hospital,  Birmingham,  etc.  Second  edition.  Crown  8vo.  pp.  427. 
London:  H.  K.  Lewis,  1883    244 


QUARTERLY  SUMMARY 


IMPROVEMENTS  AND  DISCOVERIES  IN  THE 
MEDICAL  SCIENCES. 

Anatomy  and  Physiology. 


page 

Experimental  Researches  on  the 
Biliary  Secretion.  By  Dr.  D. 
Baldi  245 


page 

Modifications  of  the  Blood  during 
Pregnancy.    By  Cohnstein       .  246 


Materia  Medica  and  Therapeutics. 


Gastro-Intestinal  Therapeutics.  By 
Prof.  Dujardin-Beaumetz  . 

The  Difference  in  the  Therapeutic 
Effect  of  Electric  Currents,  and 
the  Electro-Diagnostic  Explora- 


I     tion  of  the  Visual  Eield.  By  Dr. 

C.  Engelskjon  .        .        .  .248 
!  Double  or  Bipoplar  Uterine  Fara- 
I     dization.    By  Dr.  G.  Apastoli  .  250 
Electro-Therapeutics.    By  Dr.  A. 
I     Hughes  Bennett       .       .  .251 


Medicine. 


Examination  of  the  Blood  for  the 
Diagnosis  of  Acute  Diseases.  By 
M.  Hayem       ....  252 

Pernicious  Anamria  in  a  Child  Five 
Years  Old.  By  Dr%  Adolphe 
Kjellberg  .       .        .        .  253 

The  Nature  of  Fever,  and  the  Cold- 


Water  Treatment  of  Fever.  By 

B.  JSTaunyn       ....  254 

An  Analysis  of  Cases  of  Diphtheria. 
By  Dr.  Henoch        .        .        .  255 

Th  Symptoms  of  Rickets  con- 
sidered in  relation  to  their  Ana- 
tomical Origin.  By  M.  Kasso- 
witz  256 


16 


CONTENTS. 


PAGE 

Phosphorus  in  the  Treatment  of 
Tubercular  Disease.  By  Dr. 
Phillips  257 

Bony  Tumor  of  Brain.  By  M. 
Witkowski       .       .        .  .259 

Varices  of  the  (Esophagus.  By  M. 
Hans  Bendz     .        .        .  .260 

Infectious  and  Parasitic  Pneu- 
monia.   By  Prof.  Germain  See  261 


PAGE 

Sclerosis  of  the  Coronary  Arteries 
and  the  Affections  depending 
upon  it.    By  Prof.  Leyden       .  263 

Acute  Pancreatitis  in  Child-bed. 
By  Dr.  R.  Haidlen  .       .  .264 

Peptonuria.    By  Dr.  Grocco       .  265 

Large  Enemata  of  Nitrate  of  Silver 
in  Chronic  Dysentery.  By  Dr. 
Stephen  Mackenzie  .       .       .  265 


Surgery. 


Extirpation  of  the  Larynx.  By 
Mr.  Timothy  Holmes       .        .  266 

Wounds  of  the  Heart.  By  E.  Rose  268 

Lumbar  Nephrectomy  for  Renal 
Calculus.  By  Mr.  Henry  Morris  269 

Nephrectomy  for  Calculous  Pyeli- 
tis.   By  Dr.  E.  Sonnenburg     .  272 

Contusions  and  Ruptures  of  the  In- 
testine without  Lesion  of  the  Ab- 
dominal Wall.  By  M.  Chavasse  272 

Excision  of  a  Piece  of  Intestine. 
By  Dr.  Joseph  Grindon    .  .274 

Prolapse  of  the  Omentum  through 
the  Rectum.  By  Dr.  Domenico 
Morisani  .       .  .  .275 


Retroperitoneal  Hernia,  due  to  Ar- 
rest of  Intestinal  Development. 
By  Dr.  Carl  M.  Flirst      .  .276 

The  After-Treatment  of  Lithotomy 
when  the  Bladder  is  Sacculated 
or  Pouched.  By  Mr.  Reginald 
Harrison  .        .        .        .  .278 

Iodoform  in  Soft  Chancres.  By 
Dr.  Unna         .       .       .  .279 

The  Treatment  of  Perforating  Ul- 
cer of  the  Foot.  By  Mr.  Fred- 
erick Treves     .       .       .  .280 

Excision  of  the  Head  of  the  Femur 
for  Spontaneous  Dislocation.  By 
Mr.  William  Adams         .  .281 

Resection  of  the  Knee.  By  Prof. 
Bruns  281 


Ophthalmology  and  Otology. 


Cocaine  as  an  Anaesthetic  in  Oph- 
thalmic Practice.  By  Dr.  Karl 
Koller  283 


Chiselling  of  the  Mastoid  Process. 
By  Dr.  Arthur  Hartmann        .  284 


Midwifery  and  Gynecology. 


Craniotomy  in  Germany.  By  Dr. 
Adolph  Merkel        .       .  .286 

Separation  of  the  Symphysis  Pubis 
during  Labor.  By  Dr.  E.  F. 
Eldridge  286 

The  Value  of  Unilateral  Incisions 
for  Preventing  Ruptures  of  the 
Perineum.  By  Crede  and  Colpe  287 

Hot  Uterine  Douches  in  Post-Par- 
tum  Hemorrhage.  By  Dr.  Carl 
Regnault  288 

Diverticulum  of  the  Bladder  in  a 
Woman ;  Urethral  Ectasia  or 
Vaginal  Urethrocele.  By  Pro- 
fessor Carl  Santesson        .        .  289 


The  Treatment  of  Retro-Uterine 
Hematocele.  By  Dr.  Paul 
Zweifel    .        .       .       .  .290 

Myomotomy.    By  Martin    .  .291 

Intrauterine  Medication.  By  Dr. 
Lombe  Atthill  .        .        .  .292 

The  Alexander- Adams's  Operation 
for  Shortening  the  Round  Liga- 
ments. By  Dr.  William  Gard- 
ner  293 

Ovariotomy,  with  Suture  of  the 
Base  of  the  Tumor  into  the  Ab- 
dominal Wound.  By  Dr.  A. 
Rheinstaedter  ....  294 

Gonorrheal  Disease  of  the  Uterine 
Appendages  and  the  Operative 
Treatment.    By  Dr.  Sanger     .  295 


Medical  Jurisprudence  and  ToAcology. 


The  External  Pistol- Shot  AVounds.    By  Dr.  D.  B.  N.  Fish      .       .  .297 


THE 


AMEKICAN  JOURNAL 


OF  THE  MEDICAL  SCIENCES 


FOR   JANUARY,  1  88  5. 


Article  T. 

Injection  of  Finely  Powdered  Inorganic  Material  into  the 
Abdominal  Cavity  of  Rabbits  does  not  induce  Tuberculosis.  An 
Experimental  Research.  By  George  M.  Sternberg,  Major  and  Sur- 
geon, U.  S.  A.,  with  Pathological  Notes  by  Wm.  T.  Councilman., 
Associate  in  Pathology,  Johns  Hopkins  University. 

When  Koch  first  announced  to  the  world  his  discovery  of  the  tubercle 
bacillus,  and  gave  an  account  of  the  experimental  evidence  which  had  con- 
vinced him  of  its  essential  etiological  relation  to  the  disease  tuberculosis, 
it  was  natural  that  conservative  physicians  should  demand  additional 
evidence  and  confirmation  from  other  sources  before  accepting  his  con- 
clusions, notwithstanding  the  reputation  which  he  had  already  established 
as  an  expert  and  conscientious  investigator.  The  special  reasons  for 
exercising  an  unusual  degree  of  scientific  scepticism  in  accepting  Koch's 
account  of  the  etiology  of  this  disease  were  stated  by  the  writer  in  the 
following  language  in  a  paper  published  in  The  Medical  News,  July  1, 
1882  :— 

' '  Koch  began  this  investigation  as  an  expert,  familiar  from  long  practice  with 
the  technique  of  culture  experiments  and  microscopical  investigations  with  the 
highest  powers.  Probably  no  man  living  was  better  fitted  by  natural  aptitude 
and  past  experience  for  carrying  out  an  experimental  research  of  this  kind,  and 
certainly  very  few  would  have  been  able  to  command  as  great  confidence  in  the 
result  announced  in  advance  of  confirmation  by  other  observers.  Still  this  con- 
firmation is  necessary  in  order  to  establish  the  discovery  of  Koch  among  the  demon- 
strated truths  of  medical  science.  This  is  all  the  more  essential,  inasmuch  as  other 
observers — Klebs  and  Toussaint — have  found  in  their  experimental  researches, 
organisms,  microccocci,  believed  by  them  to  be  the  agents,  of  tuberculous  infec- 
tion, which  differ  morphologically  from  those — bacilli — described  by  Koch  ;  and 
more  especially  because  it  has  been  demonstrated  by  repeated  experiments  that  a 

No.  CLXXVII  Jan.  1885.  2 


18      Sternberg,  Production  of  Tuberculosis  by  Inoculation.  [Jan. 


disease  closely  resembling  tuberculosis,  if  not  identical  with  it,  may  be  produced 
in  animals  by  inoculation  with  a  variety  of  organic  products  of  non-tubercular 
origin,  and  even  by  the  inhalation  of  inorganic  particles.  Thus  Brunet1  inocu-. 
lated  seven  rabbits  with  cancer,  six  with  simple  pus,  and  six  with  tuberculous 
matter.  Of  these,  fourteen  became  tuberculous,  viz.,  six  of  those  inoculated 
with  cancer,  three  of  those  inoculated  with  pus,  and  five  of  those  inoculated  with 
tuberculous  matter. 

Shottelius2  found  that  miliary  nodules  in  the  lungs  resulted,  in  dogs,  alike  from 
the  inhalation  of  the  pulverized — spray — sputum  of  phthisis  and  of  bronchitis. 

Toussaint  affirms  that  the  tubercular  deposits  resulting  from  inoculation  with 
non-tubercular  material  are  not  infectious,  and  that  experimental  pseudo-tuber- 
culosis may  be  distinguished  from  tuberculosis  proper  by  inoculation  experiments, 
although  the  pathological  anatomy  of  the  two  diseases  is  identical. 

If  we  accept  the  view  that  the  tubercle  nodules  are  of  inflammatory  origin, 
we  can  readily  understand  how  both  living  and  non-living  particles  may  give  rise 
to  local  inflammatory  processes,  resulting  in  similar  pathological  products,  and 
the  infectious  or  non-infectious  character  of  these  products  would  then  be 
explained  by  the  presence  or  absence  of  living  organisms,  in  accordance  with  the 
views  of  Burdon- Sanderson,3  who  says,  '  Whenever  an  inflammation  becomes 
infectious,  it  owes  that  property  to  chemical  change  in  the  exudative  liquid,  of 
which  the  presence  of  microzymes  is  a  necessary  condition.' 

The  weight  of  experimental  evidence  seems  to  the  writer  to  favor  the  view  that 
the  specific  properties  of  Koch's  bacillus  depend  upon  its  ability  to  locate  itself 
in  certain  situations,  rather  than  in  any  power  to  produce  a  special  kind  of 
inflammation,  giving  rise  to  products  having  specific  characters.  If  this  is  the 
case,  we  should  expect  that  other  organisms  capable  of  locating  themselves  in  the 
same  situations  would  likewise  give  rise  to  tubercular  neoplasms.  In  a  recent 
communication  to  the  French  Academy  of  Sciences,  we  have  evidence  presented 
that  such  is  the  case. 

M.  Laulaine,4in  a  note  presented  by  M.  Bouley,  on  the  2d  of  January  of  the 
present  year,  makes  the  following  statements  : — 

The  author  had  recently  observed  in  the  lungs  of  a  dog  the  alterations  pro- 
duced by  the  eggs  of  a  nematoid  worm,  the  strongylus  vasorum  (Baillet),  which 
possess  great  interest,  because  of  their  apparent  identity  with  those  of  tubercu- 
losis. These  strongyles  in  the  adult  state  live  in  the  right  ventricle  and  in  the 
larger  divisions  of  the  pulmonary  artery.  Here  they  are  massed  together  in  balls 
of  greater  or  less  magnitude,  which  consist  of  individuals  of  both  sexes.  These 
masses  are  restrained  from  being  washed  away  by  the  blood  current  by  anasto- 
mosing fibrous  bands,  which  are  developed  as  the  result  of  an  endarteritis,  which 
is  infallibly  produced  by  the  presence  of  the  parasites.  The  fertilized  eggs 
emitted  by  the  females  in  these  tangled  masses  in  the  central  part  of  the  circula- 
tion, are  carried  along  by  the  current  to  the  smallest  arteries  and  capillaries, 
where  they  are  arrested  and  where  the  embryos  are  born.  These  emigrate  imme- 
diately to  the  smaller  bronchial  tubes.  The  lungs  of  dogs  infested  with  this 
parasite  are  filled  with  fine  gray  granulations,  the  histological  characters  of  which 
are  described  by  the  author  as  follows :  — 

'  The  eggs  and  the  embryos  arrested  in  the  smallest  arterioles  become  the 
point  of  departure  of  a  nodular  arteritis,  presenting  in  its  structure  all  the  char- 
acters assigned,  since  Koster,  to  the  elementary  follicles  of  tuberculosis.  At  the 
centre  of  each  nodule  is  found  an  egg  or  an  embryo  inclosed  in  a  giant  cell,  this 
is  surrounded  by  a  more  or  less  abundant  collection  of  epithelioid  cells  or  by  an 
exterior  embryonic  zone  which  tends  frequently  to  become  fibrous.' 

The  author  points  out  that  this  pseudo-tuberculosis  affects  especially  the  base 


1  Sur  la  tuberculose  experimental,  C.  R.  A.  des  Sciences,  t.  xciii.  p.  447. 

2  Experimentelle  Untersuchungen  iiber  die  Wirkung  inhalirter  Substanzen.  Archiv 
f.  Path.  Anat.  und  Phys.  lxxiii.  p.  524. 

3  The  Lumleian  Lectures  on  Inflammation.  British  Medical  Journal,  April  15, 1882, 
p.  527. 

*  Sur  une  tuberculose  parasitaire  du  chien  et  sur  la  pathogenie  du  follicule  tubercu- 
leux.    C,  R.  Ac.  des  Sci.,  i.  xciv.  p.  49. 


1885.]    Sternberg,  Production  of  Tuberculosis  by  Inoculation.  19 

of  the  pulmonary  lobes,  differing  in  tins  respect  from  true  tuberculosis  which  is 
located  by  preference  at  the  summit. 

The  present  writer  intends  to  repeat  the  experiments  of  Koch,  if  circumstances 
and  the  limited  facilities  now  at  his  command  enable  him  to  do  so,  and  if  any 
results  are  attained  worthy  of  record,  proposes  to  communicate  them  in  a  second 
paper  to  which  this  will  serve  as  an  introduction." 

In  attempting  to  carry  out  the  intention  above  announced,  the  writer, 
being  stationed  at  a  military  post  on  the  Pacific  coast,  and  depending  en- 
tirely upon  his  own  resources,  met  with  difficulties  which  prevented  him 
from  completing  his  self-imposed  task.  Many  minor  difficulties  were 
encountered,  among  which  may  be  mentioned  that  of  obtaining  ani- 
mals for  experimental  purposes,  and  the  consciousness  that  public  senti- 
ment in  the  garrison  was  opposed  to  experiments  of  this  nature,  the 
importance  of  which  was  not  appreciated,  while  exaggerated  ideas  of  the 
sufferings  of  the  animals  were  entertained,  especially  by  the  commanding 
officer's  wife.  But  the  main  difficulty  encountered  resulted  from  the  ab- 
sence of  gas,  and  of  a  suitably  constructed  culture  oven,  and  a  consequent 
failure  to  obtain  cultures  of  the  bacillus  after  all  of  the  preceding  steps  in 
the  investigation  had  been  carried  out  in  a  successful  manner. 

The  bacillus  was  found  in  tuberculous  sputum.  Rabbits  and  guinea- 
pigs  were  inoculated  with  sputum  of  phthisical  patients,  and  character- 
istic tubercle  nodules  were  found  in  the  lungs  and  liver  as  a  result  of  such 
inoculations ;  but  when  these  nodules  were  placed  with  due  precautions 
upon  the  surface  of  sterilized  blood  serum,  prepared  as  directed  by  Koch, 
they  remained  for  weeks  without  the  appearance  of  any  scales  made  up  or 
bacilli,  such  as  Koch  described  in  his  first  report  and  has  since  represented 
in  the  beautiful  chromo-lithographs1  illustrating  his  recent  elaborate 
memoir  published  in  the  second  volume  of  The  Report  of  the  Imperial 
Board  of  Health  of  Germany. 

This  failure  to  obtain  cultures  was  doubtless  due  to  imperfect  regulation 
of  temperature  in  the  improvised  culture-chamber,  which,  in  the  ab- 
sence of  anything  better,  I  attempted  to  use,  and  which  answered  very 
well  for  the  cultivation  of  various  other  micro-organisms  less  susceptible 
to  slight  variations  of  temperature. 

To  repeat  the  attempt  at  the  present  time  would  be  simply  a  matter  ot 
personal  gratification,  for  the  possibility  of  cultivating  the  bacillus  through 
successive  generations  has  been  demonstrated  beyond  question,  not  only 
by  Koch  and  his  assistants,  but  by  Watson  Cheyne,  of  London,  and  quite 
recently  in  our  own  country  by  Dr.  Ernst,  of  Massachusetts.  I  cannot, 
however,  admit  that  the  experiments  of  the  last-named  gentleman,  de- 
tailed in  his  interesting  paper  in  the  October  number  of  this  journal,  are 
by  themselves  convincing  as  to  the  essential  etiological  role  of  the  bacillus 
in  the  production  of  tuberculosis  ;  for,  in  my  opinion,  considerably  more 

1  The  writer  has  taken  the  liberty  of  introducing  into  the  second  edition  of  his  work 
on  "  Bacteria,"  a  chromo-lithographic  plate  in  which  the  figures  have  been  accurately 
copied  from  some  of  those  above  referred  to. 


20      Sternberg,  Production  of  Tuberculosis  by  Inoculation.  [Jan. 

than  three  successive  cultures  must  be  made  in  order  to  insure  the  exclu- 
sion of  any  trace  of  the  original  material,  especially  in  the  case  of  an 
organism,  which  develops  as  slowly  as  does  the  tubercle  bacillus,  and 
which  extends  but  a  limited  distance  from  the  point  of  inoculation  upon 
the  surface  of  a  solid  culture  medium. 

But  Koch  himself  has  carried  these  cultures  so  far,  and  has  multiplied 
his  inoculation  experiments  with  "pure  cultures"  to  such  an  extent  that 
the  experimental  evidence  seems  unimpeachable.  Thus,  by  reference  to 
his  latest  report,  above  referred  to,  we  find  that  in  one  series  of  experi- 
ments sixteen  successive  cultures  were  made  during  a  period  of  twelve 
months,  the  original  material  being  obtained  from  a  cavity  in  a  phthisical 
lung.  Seventeen  guinea-pigs  were  inoculated  with  the  sixteenth  culture, 
and  all  became  tuberculous  and  died  within  six  weeks.  In  another  ex- 
periment four  guinea-pigs  were  inoculated  successfully  with  the  twenty- 
sixth  culture,  the  original  material  having  been  obtained  from  a  human 
lung  eighteen  months  previously.  These  examples  represent  but  a  small 
portion  of  the  experimental  evidence  recorded  in  the  report  referred  to, 
and  the  writer  confesses  that  since  he  has  become  familiar  with  this  evi- 
dence the  last  remnant  of  scepticism  has  been  removed  from  his  mind,  and 
he  now  recognizes  not  only  that  tuberculosis  is  an  infectious  disease — a 
fact  which  had  been  prettly  well  demonstrated  prior  to  Koch's  discovery, 
and  which  I  have  repeatedly  verified  by  inoculation  experiments  with 
phthisical  sputum — but  also  that  it  is  a  parasitic  disease,  due  to  the  pres- 
ence in  the  body  of  an  infected  animal  of  the  Bacillus  tuberculosis. 

This  brings  us  to  the  question  of  the  modus  operandi  of  the  bacillus  in 
producing  the  infectious  disease,  tuberculosis.  Does  it  act  simply  as  a 
mechanical  irritant,  as  maintained  by  Form  ad,  of  Philadelphia  ?  and  may 
it  be  replaced  by  other  non-living  mechanical  irritants,  as  he  claims  to 
have  demonstrated  ?  or  does  the  pathogenic  power  of  the  bacillus  depend 
upon  specific  physiological  characters  peculiar  to  it  ? 

By  referring  to  the  extract  from  a  previous  paper,  quoted  on  page  17,  it 
will  be  seen  that  two  years  ago  the  writer  was  inclined  to  favor  the  first  men- 
tioned view,  inasmuch  as  it  seemed  to  be  supported  by  a  considerable  amount 
of  experimental  evidence,  and  because  other  experimenters — Klebs  and 
Toussaint — had  claimed  to  produce  tuberculosis  by  inoculations  with  pure 
cultures  of  a  different  micro-organism.  But  to-day  I  feel  compelled  to  admit 
that  experiments  made  prior  to  the  discovery  of  Koch's  bacillus,  especially 
when  these  were  made  in  laboratories  long  in  use  for  various  pathological 
researches,  can  be  accorded  but  little  value  on  account  of  the  great  lia- 
bility to  accidental  contamination  of  material  used  for  inoculation  experi- 
ments, or  the  subsequent  infection  of  animals  experimented  upon  through 
the  wound  made  in  these  experiments.  We  now  know  that  such  experi- 
ments can  have  no  scientific  value  in  the  absence  of  special  precautions  to 
prevent  such  accidental  inoculation,  which  precaution  no  one  thought  of 
taking  prior  to  the  discovery  of  the  tubercle  bacillus. 


1885.]    Sternberg,  Production  of  Tuberculosis  by  Inoculation.  21 

But  since  this  famous  discovery  was  first  announced,  Dr.  Formad,  of 
Philadelphia*  has  repeatedly  and  emphatically  declared  that  he  is  able  to 
produce  tuberculosis  in  rabbits,  and  in  other  animals,  by  injecting  into 
the  cavity  of  the  abdomen,  finely  powdered  inorganic  material,  such  as 
glass,  or  ultramarine  blue.  This  statement,  coming  from  a  pathologist  of 
Dr.  Formad's  reputation,  has  had  considerable  weight  with  the  writer, 
notwithstanding  the  fact  that  a  detailed  account  of  the  experiments  upon 
which  it  is  founded  has  not  yet  been  published.  Being,  then,  still  in 
doubt  with  reference  to  this  important  point,  I  determined,  soon  after 
the  meeting  of  the  American  Medical  Association  in  Washington,  in  May 
last,  to  repeat  Dr.  Formad's  experiments  with  such  precautions  as  would 
insure  the  exclusion  to  tubercle  bacilli,  and  thus  render  it  certain  if  a 
positive  result  was  obtained  that  it  was  due  solely  to  the  inorganic  particles 
introduced  and  not  to  accidental  contamination  of  the  material  injected. 

The  main  object  of  the  present  paper  is  to  give  an  account  of  these 
experiments,  which  my  assignment  to  duty  in  Baltimore,  in  June  last, 
enabled  me  to  carry  out  without  delay,  and  with  the  co-operation  of  a 
competent  pathologist,  whose  valuable  assistance  I  hereby  acknowledge, 
and  whose  notes  relating  to  the  pathological  results  of  the  injections  made 
are  embodied  in  the  present  paper.  I  am  also  indebted  to  Dr.  Councilman 
for  facilities  for  keeping  my  rabbits  in  the  country  under  such  circum- 
stances as  seemed  to  preclude  the  possibility  of  accidental  inoculation 
with  tubercle  bacilli.  The  biological  laboratory  of  Johns  Hopkins  Uni- 
versity, where  I  have  been  engaged  in  other  experimental  work  during 
the  past  summer,  is  a  new  building,  and  the  animals  might,  perhaps,  as 
well  have  been  kept  in  it,  an  arrangement  which  would  have  been  de- 
cidedly more  convenient.  But  to  avoid  all  possibility  of  accidental  con- 
tamination the  rabbits  purchased  especially  for  the  experiment — fifteen  in 
number — were  sent  directly  to  Dr.  Councilman's  home  in  the  country, 
about  eight  miles  from  Baltimore,  and  were  there  placed  in  the  loft  of  a 
storehouse,  which  had  not  previously  been  used  for  any  similar  purpose. 

I  was  particularly  desirous  that  the  experiments  should  be  made  in  a 
way  which  would  be  satisfactory  to  my  friend,  Dr.  Formad,  so  that  in  case 
of  a  negative  result  the  criticism  might  not  be  made  that  they  were  not 
properly  done,  and  that  a  different  mode  of  operating  would  have  insured 
a  different  result.  I  accordingly  invited  Dr.  Formad  to  assist  in  making 
the  experiment,  and  he  kindly  came  from  Philadelphia,  on  a  day  ap- 
pointed, for  this  purpose.  Dr  Councilman,  of  Baltimore,  was  also  pre- 
sent when  the  injections  were  made.  The  powdered  glass  used  in  the 
experiments  was  prepared  by  Dr.  Formad,  and  the  quantity  of  this,  and 
of  the  marine  blue,  to  be  injected  into  each  rabbit  was  determined  by  him. 
I  was  somewhat  surprised  at  the  considerable  quantity  of  this  material 
which  Dr.  Formad  insisted  upon  using,  for  I  had  previously  received  the 
impression  that  in  his  experiments  each  particle  served  as  a  nucleus  for 
a  tubercle  nodule,  and  consequently  that  but  a  small  quantity  of  the  finely 


22      Sternberg,  Production  of  Tuberculosis  by  Inoculation.  [Jan. 


divided  inorganic  material  would  be  required  in  order  to  obtain  a  suffi- 
ciently characteristic  result.  The  amount  used  for  each  injection  must  have 
considerably  exceeded  a  drachm,  and  I  should  judge  came  nearer  two 
drachms,  although,  as  it  was  not  weighed,  I  cannot  speak  more  definitely 
as  to  the  exact  quantity.  It  was  a  matter  of  astonishment  to  me  that 
such  an  amount  of  irritating  material  could  be  introduced  into  the  perito- 
neal cavity  of  a  delicate  animal  like  the  rabbit  without  producing  fatal 
peritonitis.  The  inflammation  which  did  occur  was  of  a  conservative  and 
chronic  kind,  as  is  shown  by  Dr.  Councilman's  post-mortem  notes,  and, 
with  two  or  three  exceptions,  the  animals  continued  in  apparent  good 
health  up  to  the  time  when  they  were  killed,  and  were  then  found  to  be 
in  good  condition,  and  in  the  case  of  young  rabbits  to  have  grown  very 
considerably  in  size.  I  ascribe  this  to  the  fact  that  the  material  had  been 
thoroughly  sterilized  by  the  method  shortly  to  be  detailed,  and  that,  con- 
sequently, no  septic  complications  occurred.  Dr.  Formad  has  informed 
me  that  in  his  own  experiments  about  one-third  of  the  animals  operated 
upon  died  during  the  first  week  from  septicemia,  and  that  a  certain  num- 
ber of  the  survivors  suffered  an  acute  inflammation,  attended  with  the 
formation  of  pus,  and  its  subsequent  discharge  through  an  opening  in  the 
walls  of  the  abdomen.  It  is  evident  that  animals  in  this  condition  would 
be  exposed  to  contract  tuberculosis  in  an  affected  locality  by  inoculation 
through  the  open  wound  in  the  belly. 

Dr.  Formad's  method,  as  described  to  me,  consisted  in  first  making  an 
incision  through  the  integument  over  the  belly  ;  in  then  plunging  a  trocar 
or  canula  into  the  cavity  of  the  abdomen  ;  and  finally,  in  injecting  the 
sterilized  material  through  the  canula  with  a  syringe.  The  wound  was 
then  closed  by  one  or  more  stitches.  The  dangers  and  possibilities  of 
accidental  infection  attending  this  mode  of  operating  were  avoided  in  my 
experiments  by  adopting  the  following  method,  the  special  advantages  of 
which  were  at  once  recognized  by  Dr.  Formad. 

The  finely  powdered  glass,  or  ultramarine  blue,  suspended  in  water,  was 
introduced  into  little  glass  flasks  with  a  long  neck,  such  as  I  constantly 


rig.  1. 


use  in  my  culture  experiments,  and  one  of 
which  is  represented  in  the  figure  in  process  of 
being  filled  with  fluid  from  the  glass  beaker. 
The  details  relating  to  the  manufacture  and 
filling  of  these  little  flasks  are  given  in  my 
work  on  "  Bacteria,"  from  which  the  figure 
is  taken.  For  this  experiment  the  flasks  were 
made  rather  larger  than  usual,  their  capacity 
being  about  a  fluidounce.  After  filling  them 
to  about  one-third  their  capacity,  the  extremity 
of  each  was  hermetically  sealed  in  the  flame 
of  an  alcohol  lamp.    The  contents  were  then 


1885.]    Sternberg,  Production  of  Tuberculosis  by  Inoculation.  23 

sterilized  by  placing  them,  for  an  hour  or  more,  in  a  water-bath  main- 
tained at  a  boiling  temperature.  • 

The  sterilized  contents  of  one  of  these  flasks  were  introduced  directly 
into  the  abdominal  cavity  of  each  rabbit  operated  upon  without  any  ex- 
posure to  the  external  atmosphere  or  contact  with  other  apparatus.  This 
was  accomplished  as  follows  :  The  capillary  extremity  was  first  passed 
through  the  flame  of  a  lamp  to  destroy  any  germs  adhering  to  its  external 
surface;  the  point  was  then  broken  off  with  sterilized  forceps,  and  was 
thrust  through  the  walls  of  the  abdomen.  By  passing  the  tube  beneath 
the  skin  for  a  short  distance,  and  then  directing  it  perpendicularly  through 
the  walls  of  the  abdomen,  a  valvular  opening  is  made,  which  prevents  the 
admission  of  air  or  the  escape  of  fluid  when  the  tube  is  withdrawn.  In 
operating  by  this  method  upon  adult  rabbits  it  is  necessary  to  make  a 
button-hole  aperture  through  the  skin  with  scissors,  but  the  slender  glass 
tube  maybe  thrust  through  the  thin  skin  of  a  young  rabbit  without  diffi- 
culty. The  contents  of  a  flask  were  injected  into  the  peritoneal  cavity  of 
each  rabbit  by  the  application  of  heat  to  its  bulbous  extremity  by  means 
of  an  alcohol  lamp.  The  expansion  of  the  inclosed  air  quickly  forced  out 
the  fluid  contents  with  the  inorganic  particles  in  suspension,  and  by  this 
simple  device  all  of  the  difficulties  attending  the  use  of  an  ordinary  syringe 
were  at  once  disposed  of. 

The  experiment  was  made  on  the  17th  of  June  ;  and  on  the  morning  of 
that  day,  before  going  to  Dr.  Councilman's  home  in  the  country,  four 
rabbits  were  injected  at  the  laboratory,  two  with  ultramarine  blue,  and 
two  with  glass.  In  the  afternoon  eight  of  the  fifteen  rabbits  in  the  country 
were  injected,  four  with  blue  and  four  with  glass,  the  remaining  seven 
being  kept  as  temoins. 

The  rabbits  injected  at  the  laboratory  were  intended  to  test  the  question 
whether  association  with  tuberculous  animals  would  make  a  difference  in 
the  result,  and  a  few  days  later  other  rabbits  injected  with  sputum,  con- 
taining the  tubercle  bacillus,  were  placed  in  the  adjoining  compartment, 
which  was  only  separated  from  that  in  which  they  were  kept  by  a  coarse 
wire  screen. 

One  of  the  four  rabbits  operated  upon  at  the  laboratory  was  much  ema- 
ciated, and  evidently  not  in  good  health.  This  animal  died  the  following 
day.  Another  of  these  rabbits  died  five  days  later,  probably  from  injury 
to  the  intestine  by  the  point  of  the  glass  tube.  On  the  15th  of  July  an- 
other of  these  laboratory  rabbits  died,  and,  upon  post-mortem  examina- 
tion by  Dr.  Councilman,  the  blue  pigment  was  found  in  the  cavity  of  the 
abdomen  in  great  quantity,  free  or  encapsuled,  and  also  in  the  lymphatics 
of  the  diaphragm  in  such  quantity  as  to  give  them  the  appearance  of 
having  been  artificially  injected.  One  rabbit  injected  with  blue  died  in 
the  country  on  the  26th  of  June,  and  one  injected  with  glass  on  the  22d 


24      Sternberg,  Production  of  Tuberculosis  by  Inoculation.  [Jan. 

of  July.  The  post-mortem  examinations  were  carefully  made  by  Dr. 
Councilman. 

The  time  fixed  by  Dr.  Formad  at  the  outset  for  terminating  the  ex- 
periment was  two  months,  and  at  my  invitation  he  again  came  to  Balti- 
more on  the  27th  of  August  to  assist  at  the  post-mortem  examination  of 
the  remaining  rabbits,  which  I  proposed  to  kill  on  that  day.  All  of  the  rab- 
bits from  the  country  were  brought  to  the  laboratory  in  Baltimore  on  the 
morning  of  the  appointed  day,  and  two  were  killed  and  carefully  exam- 
ined by  Drs.  Formad  and  Councilman  in  my  presence.  One  of  them  had 
been  injected  with  the  blue  pigment  and  one  with  glass.  Both  were  well 
nourished,  and  the  injected  material  was  in  each  case  found  in  the  cavity 
of  the  abdomen  in  great  abundance,  encapsuled  in  larger  or  smaller  masses, 
and  contained  in  the  mesenteric  glands,  in  the  lymphatics,  etc. 

A  more  exact  account  of  the  distribution  of  this  material,  and  of  the 
pathological  appearances  which  had  resulted  from  its  presence,  will  be 
found  in  Dr.  Councilman's  notes,  which  he  has  kindly  given  me  for  pub- 
lication in  connection  with  my  own  account  of  the  experiment.  As  these 
rabbits  presented  no  evidence  whatever  of  tuberculosis,  those  still  remain- 
ing were,  at  Dr.  Formad's  suggestion,  kept  for  another  month.  But,  at 
my  request,  another  rabbit,  which  had  been  inoculated  subcutaneously  with 
tuberculous  sputum  ten  days  after  the  experiment  with  inorganic  material, 
was  killed  and  examined.  This  animal  was  found  to  have  typical  tuber- 
culosis of  the  lungs,  and  the  presence  of  Koch's  bacillus  was  demonstrated 
by  Ehrlich's  method,  by  spreading  upon  thin  glass  covers  material  from 
a  caseous  axillary  gland,  and  also  from  a  crushed  tubercle  nodule  from 
the  lungs. 

One  month  later  the  remaining  rabbits  injected  on  the  17th  of  June 
were  killed  and  carefully  examined  by  Dr.  Councilman  and  myself.  They 
were  all  well  nourished,  and  none  of  them  presented  any  evidence  of 
tuberculosis,  the  lungs  and  liver  being  normal  in  appearance,  with  the 
exception  that  upon  the  surface  of  the  liver  of  a  rabbit  injected  with  glass 
there  were  small  fibrous  nodules  containing  this  material.  In  the  mean 
time  I  had  killed  another  rabbit  inoculated  with  sputum  on  the  27th  of 
June,  and,  as  before,  found  it  to  have  unmistakable  tuberculosis  of  the 
lungs.  A  third  rabbit  inoculated  with  sputum  at  the  same  time  was 
killed  a  few  days  later,  and  it  also  had  transparent  nodules  scattered 
through  the  lungs  in  which  the  presence  of  the  bacillus  tuberculosis  was 
demonstrated. 

It  is  unnecessary  to  say  that  this  experiment  gives  no  support  whatever 
to  the  claim  that  tuberculosis  may  be  induced  by  injecting  into  the 
abdominal  cavity  of  rabbits  finely  powdered  inorganic  particles,  or  to  the 
view  that  the  tubercle  bacillus  induces  tuberculosis  by  acting  simply  as  a 
mechanical  irritant. 


1885.]    Sternberg,  Production  of  Tuberculosis  by  Inoculation.  25 


Indeed  this  view  is  directly  opposed  by  a  vast  amount  of  negative  evi- 
dence familiar  to  pathologists,  but  which  has  not  heretofore  received  the 
attention  to  which  it  is  entitled.  It  is  well  known  that  the  lungs  of 
healthy  adults  contain  a  great  number  of  inorganic  particles,  which  find 
their  way  to  the  air  cells  with  the  inspired  air  and  become  fixed  in  the 
tissues  in  such  quantity  as  to  cause  a  dark-colored,  mottled  appearance 
upon  post-mortem  section.  These  particles  consist  for  the  most  part  of 
minute  angular  fragments  of  some  form  of  carbon,  and  from  their  size  and 
angular  form  it  would  seem  that  they  should  be  more  potent  as  mechani- 
cal irritants  than  the  minute  tubercle  bacillus.  I  am  informed  that  in 
Europe  the  lungs  of  men  who  have  been  employed  in  certain  glass  or 
porcelain  works  are  found  to  contain  innumerable  angular  fragments  of  this 
kind  of  material. 

Moreover  we  have  a  form  of  consumption  of  the  lung  which  is  not  due  to 
tuberculosis  and  which  is  directly  traceable  to  the  inhalation  of  inorganic 
particles  in  large  quantity.  This  disease  has  received  different  names, 
depending  upon  the  special  occupation  which  is  the  cause  of  its  develop- 
ment. Thus  at  Wheeling,  W.  Va.,  where  it  is  of  frequent  occurrence 
among  those  employed  in  the  large  nail  mills  in  that  city,  it  has  received 
the  name  of  "  nailor's  consumption."  It  is  recognized  by  pathologists  as 
being  at  the  outset  an  interstitial  pneumonia,  and  in  the  end  it  corres- 
ponds with  what  is  known  as  fibroid  phthisis.  Quite  recently  my  friend 
Dr.  Jas.  E.  Reeves,  of  Wheeling,  has  examined  numerous  specimens  of 
sputum  from  several  victims  of  this  disease,  with  reference  to  the  presence 
of  the  tubercle  bacillus.  In  no  case  has  he  been  able  to  find  it,  although 
he  is  quite  skilful  in  preparing  specimens  showing  the  bacillus  in  material 
which  contain  it,  as  I  can  testify,  having  recently  seen  some  very  beautiful 
preparations  which  he  has  mounted. 

Even  were  it  the  case  that  inorganic  particles  deposited  in  the  lungs 
may  give  rise  to  nodules  anatomically  identical  with  those  found  in  the 
infectious  disease  tuberculosis,  it  would  be  necessary  to  admit  that  these 
are  only  pseudo-tubercles  unless  it  can  be  shown  that  they  undergo  caseous 
degeneration  and  give  rise  to  an  extension  of  the  tuberculous  disease  by 
auto-infection. 

Dr.  Councilman's  Report. — At  Dr.  Sternberg's  request  I  undertook 
the  examination  of  the  rabbits  injected  with  various  inert  substances  in 
presence  of  Dr.  Formad  on  the  17th  of  June  last. 

The  pathological  changes  produced  differed  somewhat  in  those  injected 
with  blue  from  those  where  glass  was  used,  the  differences,  however,  in 
the  individual  cases  of  each  were  slight.  Four  rabbits  were  examined  that 
had  been  injected  with  blue.  One  of  these  died  June  26th.  In  this 
rabbit  a  quantity  of  serum  slightly  tinged  with  blood  was  found  in  the 
abdominal  cavity,  there  was  a  slight  fibrinous  exudation  with  tender  adhe- 


26      Sternberg,  Production  of  Tuberculosis  by  Inoculation.  [Jan. 


sions  of  the  viscera  in  a  few  places.  The  entire  peritoneum  was  slightly 
reddened  and  the  bloodvessels  injected.  There  was  no  pus  and  no 
appearance  of  a  purulent  inflammation.  The  lungs  and  other  viscera 
were  healthy.  Large  quantities  of  the  blue  pigment  were  found,  part  of 
which  was  lying  free  in  the  cavity,  part  was  enveloped  in  the  fibrinous 
exudation  or  inclosed  in  the  adhesions.  The  other  three  rabbits  were 
killed  later. 

On  opening  the  abdominal  cavity  the  blue  pigment  was  found  pretty 
well  distributed  over  the  entire  peritoneal  surface.  In  the  mesentery  a 
few  small  blue  nodules  were  found,  and  streaks  of  blue  along  the  mesen- 
teric vessels.  Circumscribed  blue  nodules  from  the  size  of  a  pin's  head 
up  to  that  of  a  pea  were  also  found  at  various  places  on  the  serous  surface 
of  the  intestines,  on  the  surface  of  the  liver,  and  on  the  spleen.  In  one 
rabbit,  on  the  posterior  surface  of  the  peritoneal  cavity,  there  were 
numerous  small  villous-like  projections  intensely  stained  with  blue,  these 
were  evidently  similar  to  the  papillary  projections  so  often  found  on  the 
human  peritoneum.  There  were  some  adhesions  between  the  various 
viscera,  principally  between  the  colon  and  caecum,  all  of  which  adhesions 
were  of  an  intensely  blue  color.  The  mesenteric  glands  were  enlarged 
and  injected  with  pigment,  the  lymphatics  of  the  diaphragm  were  marked 
out  in  blue,  and  the  lymph  glands  in  the  anterior  mediastinum  were  also 
colored.  A  slight  amount  of  blue  was  found  beneath  the  skin  at  the  point 
of  injection.  Lungs,  liver,  spleen,  kidneys,  and  intestines  healthy  save 
for  the  common  parasites  so  often  found  in  the  liver. 

An  examination  of  the  blue  nodules  on  the  liver  with  a  hand  lens 
showed  around  each  a  whitish  band  of  connective  tissue.  On  sections  of 
the  nodules  being  made,  stained  in  carmine  and  mounted  in  glycerine  or 
balsam,  they  were  seen  to  be  composed  of  masses  of  pigment  inclosed  in 
well-formed  connective  tissue.  The  smaller  nodules  were  simply  encap- 
suled ;  in  most  of  the  larger  there  was  not  only  a  layer  of  connective  tissue 
over  the  whole  nodule  but  bands  ran  through  the  pigment  dividing  it  into 
smaller  masses.  The  adhesions  were  found  to  consist  of  dense  connective 
tissue  which  inclosed  in  its  fibres  large  quantities  of  pigment. 

The  two  layers  of  the  omentum  were  generally  adherent;  in  some  places, 
.  however,  they  could  be  easily  separated.    The  membrane  was  stained  in 
carmine  and  examined  in  glycerine.    The  microscopic  appearances  were 
extremely  interesting,  and  showed  very  clearly  the  effect  of  continued 
irritation  on  a  serous  membrane  (Fig.  2). 

The  endothelial  cells,  as  seen  on  the  edges  of  the  trabecule,  were 
slightly  swollen  and  more  granular  than  in  the  normal.  At  numerous 
places  two  or  more  layers  of  cells  which  often  contained  pigment  granules 
were  seen.  At  various  places  there  were  bud-like  projections  from  the 
trabecule  which  contained  large  quantities  of  pigment,  and  were  covered 
with  endothelium.    Every  change  could  be  seen  from  a  mere  thickening 


1885.]    Sternberg,  Production  of  Tuberculosis  by  Inoculation.  27 


Fig.  2. 


Omentum  of  rabbit  after  the  injection  of  Berlin  blue  into  the  abdominal  cavity. 

of  a  trabeculum  to  a  long  process  only  connected  by  a  narrow  stalk.  Pig- 
ment was  irregularly  distributed  throughout  the  fibrous  tissue  of  the 
trabecule. 

An  examination  of  the  peritoneal  surface  elsewhere  showed  that  the 
pigment  was  mostly  distributed  in  the  lymph  spaces  and  lymphatics 
beneath  the  endothelium.  Of  its  easy  entrance  into  these  vessels  the  injec- 
tion of  the  various  lymph  glands  gives  abundant  proof.  The  endothelial 
cells  were  generally  free  from  pigment ;  only  in  a  few  places  were  found 
groups  of  large  granular  cells  (Fig.  3  A)  which  contained  it  in  large 
quantities.  These  cells  evidently  corresponded  with  the  so-called  germi- 
nating endothelium  described  by  Klein  and  others.  At  numerous  places 
all  over  the  peritoneum,  sometimes  growing  from  the  midst  of  a  group  of 
pigment-containing,  endothelial  cells,  were  long  villous-like  formations  of 
connective  tissue  (Fig.  3  B)  with  rounded  ends.  These  contained 
abundant  pigment,  and  most  probably  represented  adhesions  which  had 
become  elongated  and  finally  broken  by  traction  (Fig.  3). 

In  the  rabbits  that  had  been  injected  with  glass  the  adhesions  were 
more  numerous  and  extensive  than  in  the  others.  Numerous  nodules  of 
various  sizes  from  the  head  of  a  pin  up  to  that  of  a  bean  were  found  at 
various  places.  In  one  rabbit  a  large  whitish  mass  was  found  at  the 
point  of  injection  as  large  as  the  end  of  the  thumb.  These  masses  were 
of  a  whitish  color,  and  on  section  a  soft  mass  could  be  squeezed  out  of 
them  which  could  be  rubbed  between  the  fingers.    An  indistinct  division 


28      Sternberg,  Production  of  Tuberculosis  by  Inoculation.  [Jan. 

Fig.  3. 


From  same  rabbit  as  Fig  2.    A,  germinating  endothelium  containing  blue  pigment.    B,  papillary- 
connective  tissue  formations. 

of  the  mass  could  be  seen  on  the  surface  of  the  section.  In  the  omentum 
and  other  places  on  the  peritoneum  small  white  points  could  also  be  seen. 
No  lymph  glands  were  enlarged.  The  larger  nodules  presented  somewhat 
the  appearance  of  conglomerate  tubercles,  and  the  substance  squeezed  out 
of  them  might,  without  even  a  superficial  microscopic  examination,  be 
taken  for  a  caseous  mass.  In  like  manner  the  small  nodules  in  the 
omentum  might  have  been  taken  for  miliary  tubercles  but  they  were 
rather  too  transparent.  Microscopic  examination  set  all  doubts  at  rest. 
The  large  nodules  were  composed  of  masses  of  glass  inclosed  in  connective 
tissue.  This  not  only  inclosed  the  whole  nodule  but  large  bands  of  it 
penetrated  between  the  glass  dividing  it  up  into  small  areas.  From  these 
larger  bands  smaller  ones  were  again  given  off  (Fig.  4).  Between  these 
bands  nothing  but  minute  fragments  of  glass  and  a  few  cells  were  found. 
The  bands  of  connective  tissue  contained  numerous  bloodvessels.  The 
smaller  nodules  were  found  where  only  a  small  amount  of  glass  was 
present.  Sometimes  but  a  slight  nuclear  increase  would  be  found  around 
one  or  two  bits  of  glass ;  at  other  times  the  glass  would  be  inclosed  in  a 
small  mass  of  connective  tissue  very  rich  in  cells.  At  no  place  was  any 
glass  taken  up  by  the  tissue  or  found  in  the  lymphatics — in  striking  con- 
trast to  what  was  found  when  the  blue  was  used  for  injection.  The  adhe- 
sions were  composed  of  newly-formed  connective  tissue  rich  in  cells,  and 
contained  numerous  small  masses  of  glass  inclosed  in  a  capsule.  There 
was  also  a  good  deal  of  the  glass  irregularly  distributed  in  the  connective 
tissue. 


1885.]    Sternberg,  Production  of  Tuberculosis  by  Inoculation.  29 


Fig.  ±. 


Section  of  nodule  from  the  serous  surface  of  intestine  after  the  injection  of  powdered  glass  into 

the  abdominal  cavity. 

There  were  many  examinations  made,  both  when  the  rabbits  were 
killed  and  afterwards,  of  the  nodules  produced  from  the  blue  and  the 
glass  with  regard  to  the  presence  of  tubercle  bacilli,  but  with,  it  is  need- 
less to  say,  negative  results.  The  organs  in  which  no  changes  were  per- 
ceptible to  the  unaided  eye  were  carefully  examined  microscopically, 
numerous  sections  of  lungs,  liver,  spleen,  and  kidneys  were  made,  but  no 
pathological  changes  discovered.  In  no  instance  was  any  caseation  found, 
and  there  were  no  nodules  which  had  even  the  anatomical  structure  of 
tubercles — the  so-called  pseudo-tubercles. 

Three  rabbits  were  examined  that  had  been  injected  with  tubercular 
sputum.  In  two  of  these  the  most  typical  tuberculosis  was  produced. 
There  was  a  large  caseous  mass  at  the  point  of  injection,  the  axillary 
glands  were  caseous,  and  there  were  innumerable  caseous  nodules  in  the 
lungs,  liver,  and  elsewhere.  In  one  there  was  no  caseation  at  the  point 
of  injection  nor  were  the  lymph  glands  affected.  The  lungs,  however, 
contained  innumerable  grayish  semi-transparent  nodules,  some  single, 
others  conglomerate.  Examinations  were  made  from  all  cases,  and 
tubercle  bacilli  were  found  in  every  instance,  both  in  the  nodules  in  inter- 
nal organs,  in  the  caseous  mass  at  the  point  of  injection,  and  in  the  caseous 
lymph  glands. 

Postscript  The  following  interesting  letter  from  Dr.  Reeves,  relating 

to  a  form  of  consumption  of  the  lung  induced  by  mechanical  irritation,  but 


30      Sternberg,  Production  of  Tuberculosis  by  Inoculation.  [Jan. 


which  is  evidently  not  tubercular,  was  not  received  until  after  the  manu- 
script of  the  above  paper  had  left  my  hands.  I  therefore  append  it  as  a 
postscript.  G.  M.  S. 

Wheeling,  W.  Va.,  October  26,  18S4. 

Dear  Dr.  Sternberg  :  I  promised  you  at  St.  Louis  week  before  last,  that,  as 
soon  as  possible  after  my  return  home,  I  would  give  you  a  brief  statement  of  my 
observations  concerning  so-called  "Nailers'  Consumption,"  a  disease  which  kills 
about  80  out,  of  every  100  nailers  in  this  community  before  they  reach  the  age  ot 
55  years. 

In  "  The  Wheeling  Iron  and  Nail  District"  there  are  10  iron  and  nail  mills, 
employing  in  the  aggregate  not  less  than  7000  persons.  Of  these,  400  are  nailers, 
each  of  whom  has  charge  of  two,  three,  or  four  machines,  according  to  his  expe- 
rience and  skill  in  making  nails ;  and  the  greater  part  of  his  time  while  at  work 
is  occupied  in  grinding  his  bits  or  knives.  While  engaged  in  such  work  at  the 
rapidly-revolving  grindstones  his  hair,  beard,  and  clothing  soon  become  well 
powdered  with  the  fine  particles  of  sand  and  steel  which  float  in  his  breathing 
space  and  choke  his  bronchial  tubes. 

Nine  out  of  ten  of  these  operatives  suffer  from  hacking  cough,  accompanied 
with  dark-colored  expectoration,  and  dyspnoea,  within  the  first  year  after  they 
commence  grinding  ;  and  the  progression  of  the  pulmonary  symptoms  is  a  gradual 
descent  until  the  vital  spark  is  extinguished.  In  other  words,  there  is  at  first  a 
bronchitis ;  next,  a  chronic  interstitial  pneumonia  and  induration  of  the  lung 
tissue ;  next,  softening  and  excavation,  occasional  haemoptysis,  muco-purulent 
expectoration,  wasting  of  flesh,  hectic,  and  night-sweats. 

Several  years  ago  I  carefully  examined  136  nailers,  according  to  the  scope  of 
the  printed  schedule  herewith  inclosed,  and  out  of  that  number  found  only  one 
whom  I  regarded  entirely  free  from  pulmonary  disease.  In  all  of  the  others 
there  was  more  or  less  dulness  on  percussion,  bronchial  breathing,  increased  vocal 
resonance,  and  conduction  of  the  cardiac  sounds. 

The  post-mortem  appearances  are  quite  uniform.  The  pigmentation  of  the 
usually  contracted  lungs  is  in  proportion  to  the  number  of  years  the  subject  has 
spent  in  the  mills.  In  some  instances  the  lungs  are  as  black  as  if  they  had  been 
stained  with  ink. 

The  induration  of  lung  tissue  includes  fibrous  deposits,  varying  in  size  from 
small  nodules  to  large  masses,  and,  in  resistance  to  the  knife,  resembles  cartilage. 
In  some  instances  such  nodules  or  masses  appear  really  gritty.  The  bronchi 
are  dilated,  and  the  bronchial  glands  are  enlarged  and  hardened. 

Pleural  adhesions  are  very  common.  In  one  instance  the  pleural  surface  was 
studded  with  calcareous  deposit  in  the  form  of  very  thin  plates.  Now  and  then 
a  case  will  be  met  with  where  the  lungs  are  also  the  seat  of  tuberculosis  ;  but,  in 
such  instances,  I  doubt  not,  the  family  history,  if  questioned,  will  show  tubercu- 
lous tendency. 

During  the  last  several  months  I  have  made  frequent  careful  microscopic  ex- 
aminations of  the  sputa  from  subjects  of  "  Nailers'  Consumption,"  in  search  for 
Koch's  bacillus,  but  thus  far  with  negative  result,  notwithstanding  the  specimens 
examined  represented  the  first,  middle,  and  last  stages  of  the  disease — in  one  case 
even  so  late  as  a  few  days  before  the  death  of  the  patient.  But,  no  doubt,  I  shall 
yet  find  the  tubercle  bacillus  in  the  sputum  from  such  a  patient  for  the  reason 
just  mentioned,  in  describing  the  post-mortem  appearances,  namely,  the  lungs 
may  also  show  tuberculous  deposit. 

A  few  weeks  ago  I  picked  up,  from  the  sidewalk  or  pavement  near  my  resi- 
dence, a  portion  of  a  sputum  that  had  been  expelled  by  some  passer-by,  which 
furnished  one  of  the  best  mounts  I  possess  of  Koch's  tubercle  bacillus.  This 
fact  points  to  a  possibility  needless  here  to  mention. 

Very  truly  yours, 

James  E.  Reeves. 


1885.] 


Osler,  Jacksonian  Epilepsy. 


31 


Article  II. 

A  Contribution  to  Jacksonian  Epilepsy  and  the  Situation  of  the 
Leg  Centre.1  By  William  Osler,  M.D.,  F.R.C.P.  Lond.,  Professor  of 
Clinical  Medicine  in  the  University  of  Pennsylvania. 

The  case  here  recorded  illustrates  the  following  points  :  Epileptiform 
seizures  from  a  very  limited  lesion  ;  the  situation  of  the  leg  centre,  and 
certain  features  in  the  clinical  history  of  the  disease. 

The  present  doctrine  of  cerebral  localization  may  be  said  to  have  had 
its  origin  in  the  study  of  the  effects  of  very  limited  cortical  lesions,  and 
the  labors  of  Fritsch,  Hitzig,  Ferrier,  and  others  have  removed  the  sub- 
ject from  the  region  of  speculation  to  the  solid  ground  of  experimental 
science.  Still,  as  far  as  man  is  concerned,  while  admitting  the  great  and 
corroborative  value  of  observations  upon  dogs  and  monkeys,  the  careful 
study  of  pathological  cases  offers  the  only  means  whereby  positive 
knowledge  can  be  attained.  Year  by  year  in  the  past  decade  evidence  of 
this  nature  has  been  accumulating,  and  more  important  results  may  be 
expected  as  the  records  become  more  exact  and  scientific.  Fully  twenty 
years  ago  Dr.  Hughlings- Jackson,  studying  cases  of  unilateral  convulsions 
or  spasmodic  seizures  limited  to  one  member,  found  that  they  were  often 
associated  with  localized  spots  of  disease  on  the  surface  of  the  brain,  and 
he  suggested,  in  explanation  of  such  cases,  that  the  lesion  was  of  the 
nature  of  an  irritant  to  the  cells  of  the  gray-cortex,  which  discharged 
themselves,  so  to  speak,  in  an  irregular  and  explosive  manner,  causing  a 
convulsion  or  spasmodic  action  of  the  muscles  over  which  they  normally 
presided.  As  the  seizures  began  either  in  the  arm,  leg,  or  face,  it  was 
reasonable  to  conclude  that  the  portion  of  the  cortex  affected  was  different 
in  each  instance, — i.  e.,  there  were  actually  centres — motor  in  character — 
which  when  irritated  in  this  way  caused  the  convulsive  attacks. 

When  experiments  on  animals  demonstrated  that  the  gray  matter  was 
irritable,  and  that  stimulation  of  limited  areas  was  followed  by  contraction 
of  definite  groups  of  muscles,  Dr.  Jackson's  suggestion  of  motor  centres 
was  seen  in  its  true  light.  Ferrier's  observations  on  monkeys  enabled 
him  to  indicate  approximately  the  homologous  motor  centres  in  the  human 
brain,  and  an  extraordinary  impetus  was  thereby  given  to  the  study  of  cere- 
bral cases  bearing  upon  localization.  The  result  of  the  ten  or  twelve  years' 
work  enables  us  to  speak  with  some  degree  of  positiveness  of  the  functions 
of  certain  regions  of  the  brain.  Thus  the  motor  area  has  been  ascertained 
to  be  in  the  mid-region  embracing  the  convolutions  on  either  side  of  the 
fissure  of  Rolando.  Irritative  lesions  of  these  parts  issue  in  convulsions 
more  or  less  limited,  destructive  lesions  cause  paralysis,  local  or  generalized 


1   Eead  before  the  Medico-Chirurgical  Society  of  Montreal. 


32 


Osler,  Jacksonian  Epilepsy. 


[Jan. 


according  to  the  extent  of  the  disease.  The  other  areas  of  the  cortex 
cerebri  are  silent,  quoad  motor  effects  when  stimulated,  and  when  destroyed 
do  not  necessarily  induce  paralysis.  With  regard  to  further  specializing 
of  centres  in  the  motor  region,  as  far  as  man  is  concerned,  the  analysis  of 
cases  would  appear  to  place  the  leg  centre  in  the  upper  part  of  the  central 
convolutions,  particularly  the  part  extending  to  the  median  surface — the 
paracentral  lobule  ;  the  arm  and  hand  centre  in  the  mid-region  of  the 
central  gyri,  and  the  centres  for  the  face  and  tongue  at  the  lower  end — a 
disposition  in  each  instance  coinciding  more  or  less  closely  with  the  con- 
clusions arrived  at  by  Ferrier  from  his  observations  on  monkeys. 

Dividing  cerebral  symptoms  into  those  accompanied  with  loss  of  func- 
tion— negative,  and  those  characterized  by  excess  of  function — positive, 
the  cases  of  cortical  epilepsy  may  be  taken  as  examples  of  the  latter 
group.  In  Dr.  Jackson's  phraseology,  the  proximate  cause  of  the 
paroxysm  is  an  abnormally  highly  unstable  condition  of  the  cells  of 
the  gray  matter,  resulting  in  a  sudden  discharge.  "  Healthy  movement 
implies  a  liberation  of  energy  or  nervous  discharge  initially  by  cerebral 
cells,  at  any  rate  if  the  movement  be  a  voluntary  one.  A  convulsion, 
that  is  to  say,  a  sudden,  excessive,  rapid,  and  temporary  development  of 
movements — many  movements  '  run  up'  into  spasm  implies  of  necessity 
a  corresponding,  sudden,  etc.,  discharge."  In  a  local  spasm  only  a  few 
cells  are  in  this  highly  unstable  condition ;  in  severe  seizures  the  sudden 
and  excessive  discharge  of  the  highly  unstable  cells  overcomes,  it  is  sup- 
posed, the  resistance  of  healthy  cells  in  physiological  connection  with  those 
highly  unstable. 

These  preliminary  remarks  will  enable  the  history  of  the  case  to  be 
more  satisfactorily  followed,  and  I  may  state  too,  the  main  points  of  differ- 
ence between  these  epileptiform  seizures  and  true  epilepsy ;  the  slow 
onset,  local  in  character,  beginning  in,  or  in  mild  attacks  confined  to,  one 
limb  or  a  single  group  of  muscles  ;  the  gradual  extension  until  the  side  is 
involved,  or,  in  severe  attacks  the  entire  body ;  loss  of  consciousness  late, 
not  early  and  sudden  as  in  true  epilepsy,  and  lastly,  the  muscular  contrac- 
tions are  clonic,  rarely  or  never  tonic. 

On  November  8,  1883,  I  received  from  Dr.   the  brain  of  his 

daughter  for  examination,  and  with  it  the  following  history  :-— 

E.  L.  M.,  aged  15  years  9  mo.  When  sixteen  months  old  fell  on  her 
head  from  a  table  and  appeared  to  be  very  much  hurt,  as  she  cried  violently 
for  a  long  time  after.  She  appeared  to  be  quite  well  for  about  five  months, 
when  the  left  hand  was  noticed  to  close  firmly,  and  it  seemed  to  pain  her 
a  little  from  the  firmness  of  the  contraction.  This  continued  to  increase 
in  severity  and  frequency  for  three  months,  when  the  left  leg  became 
similarly  affected,  and  in  two  months  more  she  was  confined  to  bed,  and 
the  paroxysms  had  become  general  all  over  the  body,  the  mouth  being 
generally  fixed  open  during  a  spasm. 

These  spasms  lasted  in  this  violent  form  for  about  two  months,  she 
having  as  many  as  eight  or  ten  in  an  hour.    There  never  was  at  any 


1885.] 


Osler,  Jacksonian  Epilepsy. 


33 


time  any  loss  of  consciousness.  This  makes  about  seven  months  altogether. 
Then  suddenly  the  whole  trouble  ceased,  and  she  was  perfectly  well  and 
ran  about  as  healthy  a  specimen  of  a  child  as  could  be  seen. 

She  remained  quite  free  from  spasms  for  one  year,  when  they  returned 
in  the  same  way,  and  ran  much  the  same  course  for  six  or  seven  months, 
and  then  she  recovered  perfectly  again  for  about  the  same  length  of  time, 
and  this  went  on  till  she  was  about  eight  years  of  age,  or  about  six  years 
after  the  first  illness,  when  the  left  leg  began  to  show  signs  of  weakness 
and  gradually  the  foot  turned  in,  but  she  still  ran  about. 

To  give  an  idea  of  the  kind  of  spasms  she  had  about  that  time,  I  will 
describe  one : — 

Suppose  her  at  the  dinner  table,  she  would  suddenly  say,  "  Oh,  I  am 
going  to  have  a  spasm."  (She  knew  this  by  the  contraction  of  the  left 
hand.)  She  would  then  jump  up  and  go  to  the  sofa,  get  a  cushion,  lay  it 
down  on  the  floor,  then  lie  down  with  her  head  on  the  pillow,  and  jerk 
away  in  a  spasm  for  half  a  minute  or  a  minute  laughing  or  talking  all 
through  it,  and  never  losing  consciousness.  She  would  then  get  up,  re- 
place the  cushion,  and  come  back  to  the  table  and  finish  her  dinner. 

After  each  interval,  of  many  months,  the  seizures  were  more  severe  ; 
and  shortly  after  she  attained  her  eleventh  year,  there  was  a  return  of 
the  illness,  which  never  ceased  for  nearly  four  years,  and  during  six  weeks 
of  that  time  she  lay  unconscious,  and  had  from  fifty  to  eighty  spasms  dur- 
ing each  twenty-four  hours ;  but  as  soon  as  they  became  less  frequent,  she 
became  perfectly  conscious,  and  was  able  to  sit  up  in  bed  or  an  invalid 
chair  and  read  or  do  a  little  fancy  work,  although  the  left  hand  was  very 
feeble,  and  the  joints  of  the  fingers  would  bend  nearly  as  far  backwards 
as  they  would  forwards ;  this  condition  of  the  joints  being  the  result  of 
the  position  assumed  by  the  fingers  during  the  seizures. 

Last  Christmas,  when  she  was  nearly  fifteen  years  of  age,  the  spasms 
suddenly  ceased,  and  she  was  for  ten  months  without  them,  and  during  that 
time  she  became  fat  and  rosy. 

During  all  these  years  she  was  a  remarkably  intelligent  child,  and  even 
very  much  above  the  average,  for  without  any  education  of  any  conse- 
quence she  was  far  beyond  those  of  her  age.  Her  memory  was  something 
remarkable. 

There  were  no  signs  of  disease  on  the  body,  excepting  that  the  skin  of 
the  legs  became  very  rough  after  the  seizures  commenced  and  disappeared 
after  they  ceased. 

During  the  last  two  years  the  toes  of  first  the  right  and  then  the  left 
foot  assumed  a  brownish-yellow  appearance,  which  no  amount  of  washing 
would  remove,  and  latterly  the  skin  became  thickened,  and  small  sections 
of  this  dirty  brown  epithelium  pealed  off  and  soon  re-formed. 

There  was  very  little,  if  any,  wasting  of  the  limbs  of  the  left  side,  but 
the  foot  was  flexed  inwards  at  a  right  angle  to  the  leg,  at  last,  and  firmly 
flexed  in  that  position. 

Just  a  week  before  death,  the  spasms  returned  with  great  violence  and 
increasing  frequency,  till  they  became  almost  continuous,  and  for  two 
days  there  was  complete  unconsciousness  or  coma.  Three  hours  before 
death  the  spasms  ceased,  and  she  died  very  quietly,  as  I  suppose  from  con- 
gestion of  the  brain,  as  the  conjunctiva  were  very  much  injected  and  the 
temperature  very  high.  The  post-mortem  (so  I  was  told)  revealed  a 
very  much  congested  condition  of  the  vessels  of  the  brain. 

Just  a  week  before  she  died  she  told  the  nurse  to  be  sure  to  tell  me  to 
No.  CLXXVII  Jan.  1885.  3 


34 


Osler,  Jacksonian  Epilepsy. 


[Jan. 


have  a  post-mortem,  as  she  knew  her  case  was  a  peculiar  one,  and  that  it 
might  be  of  benefit  to  some  one  else,  and  to  the  medical  profession  in 
particular. 

In  reply  to  questions,  the  doctor  supplied  the  following  additional  infor- 
mation :  "  The  spasms  always  began  in  the  left  hand  and  never  in  the  leg. 
For  about  two  months  at  the  beginning  of  the  illness  the  hand  just  closed 
firmly  for  a  few  seconds,  and  there  was  no  twitching,  but  after  the  expira- 
tion of  the  two  months  it  always  twitched  from  the  onset  of  the  spasm. 
Frequently  she  could  be  seen  standing  with  the  hand  closed  and  jerking 
before  the  leg  became  affected,  and  she  had  to  lie  down.  The  spasms  were 
never  confined  to  the  left  leg.  When  the  leg  did  become  involved  the 
twitching  began  in  the  toes  and  ran  up  the  limb.  At  the  first  the  arm 
alone  was  affected.  When  the  spasms  became  unilateral,  the  face  would 
twitch  and  the  eyes  roll  to  the  convulsed  side.  The  left  arm  though 
feeble  was  not  stiff,  and  in  the  same  useless  state  as  the  leg. 

The  clinical  history  may  be  summarized  as  follows :  Jacksonian  epilepsy 
lasting  over  fourteen  years  ;  the  convulsions  beginning  in  the  left  hand, 
at  first  monobrachial,  then  extending  to  the  leg,  afterwards  becoming  uni- 
lateral, and  finally  general,  at  first  without  loss  of  consciousness.  For  the 
first  nine  years  of  the  illness,  remarkable  intermissions  lasting  for  six  or 
seven  months,  once  an  entire  year.  Six  years  after  the  onset  the  left  leg 
got  weak  and  stiff.  For  four  years,  the  tenth,  eleventh,  twelfth,  and 
thirteenth  of  the  illness,  the  seizures  frequent,  during  this  period,  six 
weeks'  unconsciousness  in  which  the  spasms  were  very  frequent,  fifty  to 
eighty  in  the  day.  Ten  months  prior  to  final  attacks  freedom  from  con- 
vulsions.   Intellectual  faculties  unimpaired. 

Brain  examined  on  Nov.  9th ;  organ  large  and  well  formed;  dura  nat- 
ural; hemispheres  symmetrical;  no  special  cloudiness  of  arachnoid;  Pacchi- 
onian granulations  small ;  large  and  small  vessels  of  pia  mater  enlarged, 
and  gave  a  very  congested  appearance  to  the  surface  ;  no  adhesions  of  the 
membrane^  no  spots  of  opacity  or  thickening;  the  pia  mater  stripped  off 
exposed  natural  looking  convolutions  of  a  deep  pink-gray  color;  motor 
convolutions  looked  symmetrical,  no  puckering  or  depression;  vessels  at 
base  healthy;  right  crus  badly  torn.  The  cord  was  cut  just  at  junction 
with  medulla,  in  the  lateral  aspect  of  which  there  is  also  a  laceration ; 
the  organ  was  sliced  after  the  Pitres  method.  Pre-frontal  and  pediculo- 
frontal  sections  normal.  A  section  passing  3  centimetres  in  front  of  the 
fissure  of  Rolando  shows  nothing  abnormal.  In  making  the  frontal  sec- 
tion the  knife  met  with  increased  resistance  on  the  right  side,  and  the 
section  which  passed  through  the  ascending  frontal  convolution,  exactly 
2  cm.  in  front  of  the  fissure  of  Rolando,  exposed  a  firm  fibrous  mass 
occupying  the  upper  part  of  this  convolution  in  the  superior  fasciculus  of 
white  fibres.  It  measured  14  mm.  in  width  by  15  mm.  in  vertical  length, 
was  8  mm.  from  the  surface  towards  the  longitudinal  fissure,  10  mm.  from 
the  top  of  the  convolution  at  the  margin  of  the  long  fissure,  and  15  mm. 
from  the  external  surface.  It  ran  up  to  the  gray  matter,  but  did  not 
appear  to  involve  it  except  towards  the  median  surface. 


1885.] 


Osler,  Jacksonian  Epilepsy. 


35 


In  a  section  7  or  8  mm.  behind  the  frontal  the  mass  was  still  visible  as 
a  small  round  puckered  area,  situated  just  at  the  edge  of  the  gray  matter 
at  the  bottom  of  a  sulcus  passing  into  the  asc.  frontal  from  the  fissure  of 
Rolando,  about  15  mm.  from  the  longitudinal  fissure.  It  extended  to 
within  4  or  5  mm.  of  the  fissure  of  Rolando.  Thus  the  entire  mass  was 
within  the  upper  end  of  the  asc.  frontal  gyrus,  having  an  antero-posterior 
extent  of  about  17  mm.,  and  a  vertical  diameter  of  15  or  16  mm.,  almost 
entirely  within  the  white  substance,  but  bordering  on  the  gray  matter  at 
several  places. 

Unfortunately  the  torn  state  of  the  crus  and  medulla  made  it  impossi- 
ble to  trace  any  descending  sclerosis  in  these  parts.  Histologically  the 
growth  presented  the  characters  of  a  firm  glioma,  consisting  of  1st,  and 
chiefly,  a  dense  felt-work  of  fibres,  in  places  coarse  and  devoid  of  cell 
elements ;  2d,  cells  of  various  sizes,  branched  and  fusiform,  the  processes 
of  which  could  be  directly  traced  in  connection  with  the  fibres.  Towards 
the  peripheral  part  of  the  growth  the  cells  were  more  abundant ;  3d, 
bloodvessels  pretty  numerous  and  large  considering  the  amount  of  fibrous 
tissue  in  the  mass.  The  growth  shaded  into  the  contiguous  tissue  in  a 
very  characteristic  way,  and  towards  the  gray  matter  there  was  no  sharply 
defined  border,  although  in  the  microscopic  sections  it  was  easy  to  see 
where  the  normal  tissue  began,  and  there  was  a  zone  in  which  there  were 
scattered  a  number  of  deeply  stained  small  cells  like  leucocytes.  In  most 
of  the  sections  the  ganglion  cells  of  the  contiguous  gray  matter  looked 
normal  and  their  nuclei  took  the  logwood  dye  as  usual.  On  the  side  of 
the  convolution  towards  the  fissure  of  Rolando  the  growth  directly  involved 
the  gray  cortex.  A  study  of  the  sections  did  not  appear  to  bear  out 
Klebs's  view  that  the  ganglion  cells  participate  in  the  growth. 

The  case  is  unusual  in  the  limitation  of  the  lesion  to  one  convolution 
and  to  its  fasciculus  of  white  matter,  scarcely  involving  the  gray  substance 
which  is  commonly  affected  in  cortical  epilepsy.  The  accurate  localiza- 
tion and  the  remarkable  absence  of  tissue  changes  in  the  immediate 
vicinity  give  the  case  the  nature  of  an  exact  physiological  experiment. 
It  is  the  rule  almost  for  lesions  causing  epilepiform  convulsions  to  involve 
the  cortex,  such  as  meningeal  thickening  and  growths,  exostoses,  gliomas, 
and  other  tumors  of  the  surface.  They  need  not,  however,  directly  affect 
the  motor  zone,  but  may  be  in  the  vicinity,  near  enough  to  excite  irrita- 
tion of  the  centres.  Charcot  lays  down  the  following  rule  for  guidance 
in  this  matter :  When  in  the  intervals  of  the  attacks  the  patient  has  not 
any  form  of  permanent  paralysis,  the  disease  causing  the  convulsions  is 
in  the  non-motor  zone,  but  when,  on  the  contrary,  the  patient  is  paralyzed 
in  the  intervals,  either  monoplegic  or  paraplegic,  we  may  conclude  that 
there  is  a  destructive  lesion  of  the  motor  area,  more  or  less  limited.  For 
example,  a  lesion  at  the  base  of  the  second  frontal  convolution  might  irri- 
tate the  contiguous  motor  cells  of  the  arm  centre  in  the  ascending  fronml 
and  produce  epileptiform  seizures  without  any  permanent  paralysis  ;  or,  if 


Osler,  Jacksonian  Epilepsy. 


[Jan. 


in  the  central  part  of  the  motor  convolutions,  might  produce  irritative 
effects  in  the  leg  and  face  centres  above  and  below  it,  while  at  the  same 
time  there  was  paralysis  of  the  arm  from  destruction  of  its  centre.  In 
fact  from  cortical  lesions  in  this  region  we  may  have  the  epileptiform 
seizures  without  the  paralysis,  or  there  may  be  paralysis  with  the  seizures, 
or  in  some  cases  limited  paralysis  without  convulsions.  In  the  present 
instance  there  was,  with  a  limited  lesion  of  the  motor  area,  permanent 
paralysis  with  contracture  of  one  extremity  and  epileptiform  convulsions. 

In  this  class  of  seizures  the  spasms  may  begin  in  the  hand,  the  face,  or 
the  foot,  and,  according  to  Jackson,  this  is  the  order  of  frequency,  and,  as 
a  rule,  the  attacks  begin  always  in  the  same  place.  They  may  be  confined 
to  the  one  region — monospasm,  or  may  gradually  extend  until  one  half  of 
the  body  is  involved — hemispasm.  Facial  and  brachial  monospasm  are 
more  common  than  crural.  The  attacks  may  be  limited  at  first  to  a  group 
of  muscles  in  an  extremity,  or  to  the  entire  limb.  Thus,  in  the  case  of 
the  patient  with  this  disease,  which  I  showed  at  the  society  some  months 
ago,  there  was  brachial  monospasm,  and  in  the  one  under  consideration, 
the  doctor  states  that  the  child  might  be  seen  standing  while  the  arm  was 
convulsed. 

The  order  of  spreading  is  important;  it  is  usually  up  a  limb,  but  it  may 
be  in  the  opposite  direction,  and  in  the  event  of  the  monospasm  extending 
it  is  more  common  for  the  face  to  be  involved  with  the  arm,  or  vice  versa, 
and  the  leg  with  the  arm,  than  the  leg  with  the  face.  Here  from  what  can 
be  gathered  the  order  of  march  of  the  spasm  was  up  the  arm,  then  the  leg 
became  affected,  and  afterwards  the  face.  This  is  unusual ;  it  is  more 
common  for  the  leg  to  be  affected  last.  Complete  details,  however,  of  the 
precise  sequence  of  the  spasms  are  wanting.  Evidently  at  first  there  was 
brachial  monospasm,  then  extension  to  the  leg,  and  later  hemispasm  with 
rolling  of  the  eyes  and  affection  of  the  face  muscles.  Within  six  months 
from  the  origin  of  the  trouble  the  seizures  had  become  general,  but  the 
doctor  says  there  was  up  to  this  time  no  loss  of  consciousness,  such  as 
subsequently  took  place. 

The  extension  of  the  convulsions  to  the  other  side  is  explained  in  one  of 
two  ways ;  either  through  the  direct  pyramidal  fasciculi  with  which  each 
side  of  the  brain  is  connected  in  a  greater  or  less  degree  with  the  same 
side  of  the  body,  or  more  probably,  on  Broadbent's  theory,  that  it  is  owing 
to  "  active  conditions  of  the  decussating  fibres  putting  in  action  the  associ- 
ated nuclei  of  both  sides  of  the  cord,  and  then  the  bilaterally  acting 
muscles  of  both  sides  of  the  body."  The  discharge  of  the  nerve  cells  of 
the  cortex  cerebri  excites  the  motor  nuclei  of  the  cord,  and  the  violent 
impulses  pass  from  the  spiral  ganglia  to  the  muscles.  Now  it  is  easy  to 
conceive  that  when  the  discharges  are  excessive  and  violent,  the  ganglia 
of  the  other  side  of  the  cord  may  be  excited  through  the  commissural 
fibres  which  unite  the  nerve  cells  of  the  anterior  horns. 


1885.] 


Osler,  Jacksonian  Epilepsy. 


37 


The  long  duration,  fourteen  years,  of  a  glioma,  is  not  without  parallel. 
Dr.  Jackson  has  recorded  two  cases,  in  one  of  which  the  fits  lasted  ten, 
and  in  the  other  twelve  years.  Cerebral  gliomata  are  benign  growths, 
which  grow  slowly  and  never  produce  metastases. 

The  other  feature  of  interest  in  this  case  is  the  light  it  throws  on  the 
situation  of  the  leg  centre.  Ferrier  placed  this  in  monkeys  at  the  gyri  at 
the  upper  end  of  the  fissure  of  Rolando,  and  the  result  of  pathological  in- 
vestigations in  man  point  to  the  same  situation.  Cases  of  uncomplicated 
crural  monospasm,  or  monoplegia  are  not  common,  but  in  the  observations 
analyzed  and  collected  by  Ferrier  and  by  Charcot  and  Pitres,  the  lesion 
was  in  each  instance  in  the  upper  part  of  the  central  gyri,  or  in  their  ex- 
tension on  the  median  surface.  When  this  part  is  simply  irritated,  there 
may  be  spasms  beginning  in,  or  limited  to,  the  foot  and  leg  ;  when  the  seat 
of  a  destructive  lesion  there  is  crural  monoplegia.  In  their  latest  work,1 
MM.  Charcot  and  Pitres  bring  forward  additional  evidence  in  support 
of  this  view.  In  the  case  here  recorded,  the  fibrous  mass  was  situated 
entirely  within  the  anterior  part  of  the  paracental  lobule,  limited  in  ex- 
tent, confined  chiefly  to  the  medullary  fibres  of  the  superior  frontal  fasci- 
culus, and  only  touched  the  gray  matter  in  places.  A  point  to  be  referred 
to  is  the  absence  of  the  paralysis  of  the  leg  for  the  first  six  years — for  if 
the  convulsions  and  monoplegia  were  caused  by  the  same  legion,  how  ex- 
plain the  late  onset  of  the  latter?  From  the  fibroid  state  of  the  tumor,  it 
might  reasonably  be  inferred  that  it  was  originally  larger,  and  had  shrunk, 
but  the  absence  of  puckering  on  the  surface,  and  the  way  in  which  the 
margins  merged  with  the  contiguous  parts,  make  it  probable  that  the 
growth  was  always  small — so  small,  in  fact,  that  at  one  period  of  its  de- 
velopment it  may  have  caused  sufficient  irritation  to  induce  the  convul- 
sions, and  yet  at  the  same  time  not  involved  the  special  fasciculi  of  white 
fibres  to  the  extent  of  producing  weakness  of  the  leg  or  monoplegia. 

In  the  clinical  history,  the  duration,  fourteen  years,  is  the  most 
remarkable  feature ;  it  is  rare  for  cases  of  cortical  epilepsy  to  run  such  a 
prolonged  course.  The  irregularity  of  the  seizures,  the  long  intervals  and 
attacks  of  coma,  which  characterize  so  large  a  proportion  of  these  cases, 
are  phenomena  not  less  difficult  of  explanation  here  where  a  lesion  is 
present,  than  in  cases  of  ordinary  epilepsy  in  which  coarse  alterations  are 
not  usually  met  with. 


1  Eevue  de  Medecine,  Octobre,  1883. 


38     Van  Bibber,  Intermediate  Hospitals  for  Mental  Diseases.  [Jan. 


Article  III. 

Intermediate  Hospitals  for  the  Treatment  of  Acute  Mental 
Diseases.    By  John  Van  Bibber,  M.D.,  of  Baltimore. 

The  nervous  system  has  of  late  years  claimed  the  attention  and  study 
of  the  best  medical  minds  of  all  countries,  and  it  is  now  an  evidence  of  a 
still  further  progress  in  this  direction,  that  mental  diseases  are  no  longer 
allowed  to  remain  in  the  hands  of  asylum-superintendents,  but  are  begin- 
ning to  demand  the  care  and  investigation  that  they  undoubtedly  deserve 
from  a  larger  and  more  active  class  of  specialists.  It  is  by  the  medium  of 
this  development  that  I  have  been  led  at  various  periods,  during  the  past 
five  years,  to  investigate  the  plan  of  treatment  and  the  management  of 
insane  asylums,  both  in  this  country  and  in  Europe.  And  everywhere, 
both  at  home  and  abroad,  I  have  been  impressed  with  the  lonely  and 
isolated  position  which  mental  diseases  hold  in  the  estimation  of  the 
general  profession,  and  I  may  add,  in  the  opinion  of  those  who  devote 
their  lives  to  the  care  and  treatment  of  insanity. 

Indeed,  it  must  seem  strange  to  any  one  who  will  devote  much  thought 
to  the  subject,  that  acute  mental  trouble  should  be  segregated  like  small- 
pox, or  some  dreadful  contagion,  far  removed  from  most  humanizing  influ- 
ences, and  immured  in  more  or  less  dreary,  but  always  crowded  asylums, 
where  each  patient,  whether  irritable,  excited,  or  convalescent,  is  forced 
into  the  companionship  with  lunatics,  and  where  both  patients  and 
physicians  suffer  the  evil  effects  of  a  moral  and  social  quarantine. 

Now,  although  a  man  either  of  sound  or  unsound  mind  can  endure  the 
enervating  and  dispiriting  effects  of  life  under  the  blighting  influence  of 
a  shadow,  which  makes  humanity  look  hideous,  and  makes  effort  seem 
almost  useless,  yet  it  is  a  question  whether  the  physician  or  patients  are 
at  their  best  in  such  an  atmosphere,  whether  the  one  can  progress  and 
prosper  in  his  science,  or  the  other  derive  the  best  advantages  from  a 
delicate  and  careful  treatment. 

It  is,  in  fact,  a  curious  tradition,  which  is  blindly  accepted  by  most 
people,  that  insanity  differs  entirely  from  any  other  form  of  disease,  that 
it  must  be  removed  from  sight,  and,  if  possible,  from  remembrance,  and 
treated  only  by  medical  men  who  live  within  the  walls  of  an  asylum,  and 
devote  their  lives  to  the  care  of  this  class  of  patients.  No  less  is  it  a 
matter  of  general  belief  that  the  institutions  in  which  this  malady  is 
treated  are  not  hospitals  but  asylums,  that  their  use  and  purpose,  though 
known,  is  in  some  way  mysterious,  and  their  existence  stands  outside  and 
apart  from  the  ordinary  ministrations  of  men. 

This  uncanny  reputation  is  clearly  the  result  of  prejudice,  and  to  some 
extent  the  result  of  the  present  system  of  treating  and  caring  for  a  most 
unfortunate  class  of  sufferers.    It  is  the  remnant  of  that  feeling  which, 


1885.]   Van  Bibber,  Intermediate  Hospitals  for  Mental  Diseases.  39 

years  ago,  built  prisons  for  the  safekeeping  of  lunatics,  and  which  em- 
ployed chains  and  manacles  as  the  treatment  for  their  disease.  AVe  have 
developed  safely  beyond  that  dark  period,  and,  with  rare  exceptions,  we 
have  even  passed  the  epoch  of  restraint. 

But  there- are  other  changes  which,  in  our  present  advancement,  are  as 
necessary  and  imperative  to  secure  the  better  and  more  successful  treat- 
ment of  cases  of  acute  insanity. 

These  changes  must  effect  many  of  the  characteristic  arrangements  of 
insane  asylums,  the  medical  officer  in  his  double  role  of  physician  and 
superintendent,  and  the  crowding  of  large  asylums  with  acute  and  chronic 
cases.  This  reform  must  also  bring  about  the  establishment  of  inter- 
mediate hospitals  for  the  treatment  of  acute  cases  of  insanity,  and  the 
gradual  development  of  large  asylums  into  homes  for  incurable  and  chronic 
cases. 

To  discuss  the  clauses  separately  and  somewhat  in  detail,  let  us  com- 
mence with  the  duties  of  the  medical  superintendent  of  any  insane  asylum, 
and  the  position  which  such  an  institution  should  hold  as  a  place  devoted 
to  the  cure  of  diseases  rather  than  the  incarceration  of  lunatics.  In 
other  hospitals  where  patients  are  received,  diseases  treated,  sufferings 
mitigated,  and  cures  fortunately  brought  about,  communication  with  the 
outside  world  is  constant  and  beneficial.  It  comes  through  the  medical 
officers,  who  call  daily,  fresh  from  the  varied  experience  of  life,  from 
friends  who  are  not  frightened  away  by  too  stringent  rules,  though  mem- 
bers of  associations  whose  benevolent  purpose  is  to  make  the  dreary  time 
of  sickness  less  heavy  and  insupportable.  But  none  of  these  healthy  regu- 
lations exist  in  the  management  of  the  average  insane  asylum.  The 
physicians  are  forced  to  live  in  the  asylums,  and,  indeed,  by  many  it  is 
considered  an  absolute  necessity  for  them  to  spend  their  lives  and  their 
energies  in  the  management  of  these  institutions.  It  is  on  this  factor  of 
management  that  I  shall  place  the  greatest  emphasis,  for  I  find  it,  in  all 
my  observations,  the  greatest  enemy  to  the  scientific  and  curative  treat- 
ment of  insanity.  As  the  management  of  an  institution  interferes  most 
materially  and  effectually  with  the  higher  and  more  necessary  duties  of  the 
physician,  this  officer  must  be  relieved  of  such  an  incubus  before  he  can 
properly  attend  to  the  medical  wants  of  his  patient.  Though  it  is  claimed 
as  necessary  for  the  medical  head  of  an  asylum  to  live  in  the  institution, 
and  that  his  peculiar  responsibilities  require  him  to  be  always  on  the  spot,  I 
think  this  regulation  is  a  decided  mistake,  and  has  been  the  cause  of  many 
of  the  most  serious  objections  to  the  present  system.  It  is  a  matter  of  daily 
observation  that  surgeons,  who  should  have  the  most  especial  care  and 
supervision  over  the  cases  they  operate  upon,  do  not  live  in  the  hospitals 
where  they  have  their  greatest  responsibilities.  After  the  most  critical 
operations  they  leave  the  case  in  the  hands  of  a  competent  assistant,  and 
at  the  appointed  time  they  return  to  their  patients,  again  to  leave  them 


40     Van  Bibber,  Intermediate  Hospitals  for  Mental  Diseases.  [Jan. 

after  the  proper  observations.  Physicians  who  attend  the  most  acute  dis- 
eases which  require  the  closest  scrutiny  from  hour  to  hour,  find  success 
and  reputation  outside  the  gloomy  routine  of  hospitals,  and  if  they  secluded 
themselves  in  order  to  treat  only  cases  coming  within  the  four  walls  of  an 
institution,  I  doubt  if  their  skill  or  reputation  would  be  as  great  as  when 
developed  by  a  more  liberal  and  extended  practice. 

There  is  no  reason,  except  the  tyrannical  demand  of  custom,  which 
should  prevent  the  medical  officers  of  an  insane  asylum  from  availing  them- 
selves of  all  the  advantages  which  the  experience  of  private  practice  could 
give  them.  Yet  they  are  not  allowed  to  practise.  They  are  forced  to 
give  all  their  time  and  energy  to  the  management  of  the  asylum.  It  is  a 
narrow  world  to  live  in,  and  it  is  beyond  human  nature  to  expect  that 
they  should  not  become  routinists  in  their  practice,  and  fail  to  excite  in 
their  assistants  that  desire  for  investigation  and  research  which  forms  the 
basis  of  all  accurate  scientific  knowledge. 

No  class  of  men  so  thoroughly  deserve  the  consideration  of  the  public  as 
the  medical  officers  of  an  insane  asylum.  Their  duties  are  onerous,  and 
most  of  them  of  no  professional  interest.  The  superintendent  of  a  large 
asylum  does  not  long  remain  a  doctor  after  he  has  assumed  his  duties. 
All  his  efforts  to  treat  insanity  soon  dwindle  into  some  administrative 
hobby,  and  the  best  intentions  for  the  advancement  of  medical  science 
become  inevitably  developed  into  ideas  of  economy  and  management. 
He  is  now  a  manager.  The  mainspring  of  every  asylum  is  how  much  per 
day,  how  much  per  week  ?    What  is  your  appropriation  ? 

By  the  present  arrangement  a  man  is  so  handicapped  in  his  medical 
duties  by  the  petty  but  necessary  detail  of  his  work  as  superintendent,  that 
with  the  best  intentions  and  the  most  sincere  desire  to  do  his  whole  duty, 
I  doubt  if  he  can  accomplish  much  satisfactory  work  in  the  medical  part 
of  his  office.  With  the  crowded  wards  and  the  complex  duties  of  a  large 
asylum  to  claim  his  immediate  attention,  I  doubt  if  any  man  can  keep  up 
his  medical  interest  in  insanity.  Though  the  morning  may  bring  new  hope, 
and  the  evening  brings  him  the  satisfaction  of  duty  done,  though  his  energy 
and  perseverance  may  follow  closely  upon  his  ambition,  he  has  in  this 
office  Augean  stables  to  clean  out,  and  the  stone  of  Sisyphus  to  roll  up. 

I  have  been  taught  in  my  observations  of  asylums  that  insanity  is  a 
disease  not  to  be  treated,  but  to  be  fed  and  managed  ;  yet  these  are  the 
schools  in  which  we  are  to  study,  and  this  is  the  lesson  that  we  learn. 
For  in  few  medical  schools  is  there  any  instruction  on  the  diseases  of  the 
mind,  and  if  there  is  any  provision  for  such  teaching,  it  is  of  the  most 
elementary  and  superficial  character.  There  is  a  very  moderate  amount 
of  theoretical  teaching  on  the  subject  of  insanity,  and  the  enormous  mass 
of  clinical  material  which  is  hidden  behind  the  asylum  walls  is  almost 
entirely  overlooked  by  the  medical  staff  of  those  institutions.  The  inter- 
esting and  curable  cases  of  insanity  are  often  lost  under  the  shadow  of 


1885.]   Van  Bibber,  Intermediate  Hospitals  for  Mental  Diseases.  41 

the  chronic  patients,  and  from  want  of  active  treatment  and  attentive 
care  they  finally  fall  into  the  large  percentage  of  this  latter  class.  Under 
the  present  system  of  huge  asylums  and  over-worked  superintendents  can 
we  expect  any  other  result  than  this  ?  The  question  is,  Can  the  system  be 
changed  ?  This  is  the  theme  of  to-day.  Shall  we  allow  the  most  inter- 
esting problem  of  medicine  to  sink  deeper  into  the  rut  of  neglect,  and 
suffer  from  the  slavery  of  an  injurious  routine  ?  Shall  we  permit  the 
troubles  of  the  mind  to  suffer  the  want  of  that  medical  attention  which  a 
fractured  leg  or  a  diseased  liver  can  command  in  any  hospital  in  the 
country  ?  Shall  we  allow  the  hideous  melancholy  of  insanity  to  languish 
beyond  the  reach  of  progress  and  advancement,  secured  behind  the  dull 
routine  of  asylum  walls  ?  No  !  The  natural  instincts  of  humanity,  the 
ambition  for  medical  progress,  the  desire  to  contend  more  successfully 
against  the  horrors  of  a  dreadful  malady,  all  these  interests  forbid  that  this 
dark  spot  on  the  civilization  of  the  19th  century  should  be  so  pronounced 
and  flagrant.  We  must  investigate  the  reasons  which  have  led  to  the 
stagnation  in  this  branch  of  medicine,  and  afterwards  endeavor  to  find 
out  the  best  methods  to  contend  against  the  evil  influence  of  the  past,  and 
secure  progress  and  advancement  in  the  future. 

In  an  isolated  and  disadvantageous  position  the  subject  of  insanity  has 
suffered  the  want  of  the  active  philanthropic  interest  which  many  of  the 
miseries  of  mankind  have  developed.  Thus  the  care  of  the  insane  has 
either  devolved  upon  the  local  or  state  governments,  or  upon  the  guardian- 
ship of  lay  and  non-medical  trustees.  Without  any  decided  or  influential 
medical  interest  in  the  organization  and  management  of  insane  asylums, 
the  equipment  of  these  institutions  has  been  neither  progressive  nor  satis- 
factory, and  as  a  result  of  such  adverse  circumstances,  we  find  the  huge 
asylums  of  the  various  States  in  a  crowded  condition,  where  patients  are 
received  in  excessive  numbers  to  be  fed  by  wholesale,  clothed  by  whole- 
sale, and  treated  by  wholesale.  In  this  large  and  general  distribution  of 
treatment  there  must  be  many  omissions  and  many  errors,  and  though 
there  are  numerous  other  arguments  against  large  and  crowded  asylums 
that  should  be  considered,  still  the  emphatic  necessity  for  more  careful 
treatment  would  be  ample  ground  for  a  radical  and  decided  change. 

How  this  improvement  is  to  be  brought  about  is  a  question  which  is 
difficult  to  solve.  Under  the  mistaken  judgment  of  those  who  have  had 
the  supervision  of  insane  patients  in  every  portion  of  the  country,  this 
unfortunate  class  of  our  population  has  proved  an  expensive  burden.  The 
dominant  idea  which  seems  to  have  governed  these  officials  in  most  cases, 
has  been  the  desire  for  handsome  and  showy  buildings.  Hence  these 
immense  structures  stand  to-day,  in  their  unwieldy  costliness,  a  barrier  to 
a  more  rational  system  of  treating  acute  insanity.  The  medical  officers 
are  helpless.  Nearly  every  year  the  American  Association  of  Insane 
Asylum  Superintendents  protest  against  large  institutions  as  opposed  to 


42      Van  Bibb ee,  Intermediate  Hospitals  for  Mental  Diseases.  [Jan. 


the  best  interests  of  the  patients,  but  each  year  is  uneventful  in  the  devel- 
opment of  any  change  in  the  vast  crowding  together  of  all  classes  of 
insane  patients  under  one  roof.  It  is  clearly  impossible  that  one  man 
should  be  able  to  study  the  ailments  of  from  900  to  1200  patients,  look 
after  their  physical  wants,  talk  to  their  relations,  and  attend  to  the  general 
management  of  the  asylum. 

According  to  the  last  annual  report  of  the  Commission  in  Lunacy, 
there  were  78,584  certified  insane  patients  in  England  and  Wales.  Of  this 
number,  how  many  are  treated  ?  If  a  certain  percentage  of  this  army  of 
insane  are  curable,  are  they  in  a  position  to  be  properly  treated  ?  These 
vital  questions  cannot  be  accurately  or  even  approximately  answered,  but  the 
interrogation  gives  us  some  idea  of  the  good  to  be  accomplished  by  the 
improvement  in  the  system  and  the  facilities  for  treating  curable  cases  of 
insanity.  To  bring  about  this  improvement  it  will  be  necessary  to  change 
the  character  of  the  institutions  devoted  to  the  care  of  the  insane ;  to 
transform  them  from  asylums  into  hospitals  ;  and  it  will  be  necessary  to 
change  the  character  of  the  medical  officers  charged  with  the  important 
duty  of  treating  insane  patients,  relieving  them  absolutely  of  all  duties 
which  conflict  with  their  medical  standing  and  progress. 

But  another  influence  is  at  work  which  will  have  a  most  stimulating  and 
beneficial  effect  upon  the  definite  progress  of  psychology.  The  division 
so  long  existing  between  insanity  and  general  nervous  diseases,  is  now 
about  to  be  broken  down,  and  the  whole  subject  included  under  one  head. 
The  line  dividing  some  general  nervous  troubles  from  actual  insanity  is 
very  difficult  to  establish,  and  the  treatment  of  the  two  classes  of  cases 
must  inevitably  come  under  the  care  of  the  same  specialist.  There 
is  no.  reason,  either  on  physiological  or  therapeutical  grounds,  why  the 
neurologist  should  not  include  mental  diseases  in  his  study  and  prac- 
tice, and  the  only  factor  which  has  prevented  this  natural  division  of  the 
subject  has  been  the  peculiar  organization  of  insane  asylums.  But  it  is 
now  some  time  since  the  movement  has  commenced  which  will  unite 
insanity  to  the  duties  of  those  specialists  who  attend  only  to  diseases  of 
the  nervous  system,  and,  if  the  effort  which  is  being  made  to  secure  cura- 
tive hospitals  for  acute  insanity  should  succeed,  the  study  of  mental  trou- 
bles will  receive  a  great  and  decided  impetus.  In  England  and  on  the 
continent  this  tendency  is  looked  upon  as  a  most  important  progressive 
step,  and  I  do  not  remember,  in  all  my  observations  among  neurologists 
or  psychologists  abroad,  to  have  found  one  man  who  was  opposed  to  its 
widening  and  healthy  influence.  In  fact  I  have  heard  from  a  distinguished 
authority  on  insanity  in  England  that  he  looked  forward  to  the  entrance 
of  a  new  medical  element  into  the  field  of  mental  troubles  with  the  highest 
hope  for  improvement  in  asylums,  and  progress  in  the  successful  treatment 
of  disease. 

The  large  asylums  and  the  combination  of  physician  and  superintend- 


1885.]    Van  Bibber,  Intermediate  Hospitals  for  Mental  Diseases.  43 

ent  is  not  at  all  an  American  outgrowth.  It  exists  elsewhere,  and  especi- 
ally in  England,  where  these  two  objectionable  points  have  reached  a  high 
degree  of  unpopularity.  The  Lancet  of  August  23d  has  a  leading  article 
on  "  Our  Monster  County  Lunatic  Asylums,"  in  which  it  refers  to  the 
fact  that  these  institutions  were  becoming  unwieldy,  and  "  that  in  some 
cases  1500  or  2000  insane  individuals,  supposed  to  be  patients,  are  con- 
gregated under  what  is  practically  one  roof,  and  under  the  care  and  con- 
trol of  one  medical  man."  This  article  goes  on  to  say  that  if  these  mon- 
ster institutions  are  intended  solely  for  the  care  of  the  insane,  of  course 
there  is  nothing  to  say  against  them,  but  if,  on  the  other  hand,  "  they  are 
intended  as  curative  establishments,  their  constitution  is  a  delusion  and 
a  snare."  The  same  article  refers  to  separation  of  the  cure  department 
from  the  care  department  of  the  insane,  and  says,  "  while  for  the  latter 
object  large  institutions  are  not  harmful,  and  may  be  necessary,  the  estab- 
lishment of  small  lunatic  hospitals  is  in  many  ways  imperative  for  the 
former." 

I  find  this  editorial  so  in  unison  with  my  own  ideas,  that  I  must  quote 
again  even  at  the  risk  of  repeating  my  own  words.  "  It  does  not  admit 
of  question  or  dispute,"  says  this  authority,  "  that  from  the  large  amount 
of  administrative  work  necessarily  devolving  on  the  medical  head  of  one 
of  these  huge  asylums,  his  medical  functions  are  practically  in  abeyance. 
In  saying  this  we  give  the  explanation  of  the  comparative  stagnation  of 
the  special  department  of  medicine  under  consideration,  for  whilst  other 
branches  of  the  art  are  advancing  by  leaps  and  bounds,  psychological 
medicine,  if  not  altogether  stationary,  manifests  at  best  but  a  lame  and 
halting  progress. 

In  answer  to  this  article  I  read  in  the  next  number  of  The  Lancet  a 
letter  from  the  medical  officer  of  a  large  county  asylum  in  which  he 
agrees  most  heartily  with  the  opinions  expressed,  and  adds  his  own  con- 
demnation of  the  present  system.  This  voice  comes  from  the  active  pur- 
suit of  a  special  work,  from  a  position  where  difficulties  and  defects  can  be 
most  keenly  felt,  and  does  great  credit  to  the  author,  for  many  men  occu- 
pying similar  positions  seem  contented  to  accept  the  present  situation  with- 
out an  effort  for  progress  or  reform. 

It  is  not  my  purpose  in  this  article  to  allude  in  detail  to  the  omissions 
and  abuses  which  prove,  that,  in  the  present  method  of  asylum  treatment, 
patients  are  neglected,  and  in  many  cases  treated  in  a  manner  likely  to 
prove  injurious.  I  will,  however,  select  one  example  from  my  observa- 
tions. In  one  of  the  largest  and  best  public  asylums  in  London,  I  had 
the  following  experience  during  a  morning  visit  to  the  patients  with  the 
physician  and  three  assistants.  We  went  into  the  yard  where  probably 
thirty  men  were  trying  to  amuse  themselves,  and  we  were  immediately 
surrounded  by  small  groups  of  them,  each  having  his  complaint  to  make. 
There  was  no  effort  to  hear  each  privately,  as  many  could  crowd  around 


44     Van  Bibber,  Intermediate  Hospitals  for  Mental  Diseases.  [Jan. 

the  speaker  as  were  so  inclined.  After  several  had  recited  their  woes  to 
this  semi-medical  and  semi-insane  audience,  a  fine-looking  fellow  came 
up  and  said  he  had  a  complaint  to  make  against  one  of  the  patients  who 
had  stolen  his  tobacco-pouch.  The  accused  promptly  denied  it,  and 
accused  his  accuser  of  taking  his  scarf  pin.  During  this  heated  conver- 
sation there  was  much  anger  shown  on  both  sides,  and  a  decided  amount 
of  unnecessary  excitement.  The  doctor  tried  to  calm  and  satisfy  them, 
but  they  refused  to  be  appeased.  We  went  on  to  listen  to  the  other  pa- 
tients in  the  yard,  but  before  we  left  the  inclosure,  both  the  patients 
referred  to  above  were  in  a  very  excitable  and  nervous  condition.  One 
was  crying  hysterically,  and  the  other  had  forgotten  his  original  trouble, 
and  had  entered  into  a  dispute  about  the  cause  of  his  being  placed  in  an 
asylum,  about  the  insulting  manner  of  the  doctor  to  him,  and  all  sorts  of 
magnified  and  exaggerated  ideas.  Now  it  seems  to  me  that  it  would  have 
avoided  this  evident  cause  of  excitement  if  the  physician  had  seen  these 
patients  separately  in  his  office ;  it  would  have  been  more  dignified  for 
him,  it  would  have  been  less  exciting  for  them,  and  he  could  have  better 
allayed  their  passing  excitement.  Practising  only  in  a  hospital  makes  us 
forget  the  finer  susceptibilities  of  our  patients,  and  we  are  apt  to  forget 
that  their  feelings  must,  to  some  extent,  be  consulted.  But  it  has  for 
years  been  the  custom  of  the  hospitals  to  see  patients  in  this  manner,  and 
it  is  not  considered  worth  while  to  progress  or  change. 

The  plan  of  treatment  would  necessarily  be  much  more  detailed  in 
small  hospitals  for  acute  mental  diseases,  than  could  be  possible  in  an 
asylum  where  the  number  of  patients  is  so  large.  The  usual  corridor  or 
yard  visit  of  the  physician  of  an  asylum  is  the  familiar  and  casual  inci- 
dent of  a  good  morning.  This  does  not  have  the  proper  effect  on  the 
patients,  nor  is  it  the  most  dignified  position  for  the  physician,  and  I  think 
it  is  in  many  respects  to  be  criticized.  If  these  patients  are  suffering  from 
a  disease,  it  deserves  some  treatment,  and  in  order  to  treat  it  properly 
and  in  a  thorough  manner,  it  must  be  investigated  and  studied.  The  air- 
ing court  is  not  the  proper  place  for  an  official  visit,  and  though  many  of 
the  patients  may  be  unable  to  recognize  this  fact,  still  the  few  who  can 
observe  its  carelessness,  will  not  fail  to  do  it. 

It  could  certainly  do  no  harm,  to  be  more  particular  to  have  the 
patients  think  that  each  day  a  proper  interest  was  taken  in  their  cases,  and 
that  they  were  under  treatment,  even  if  it  was  necessary  to  reduce  its 
scope  to  the  deception  of  a  placebo. 

After  close  observation  and  careful  study,  I  have  come  to  the  conclu- 
sion that  many  of  the  evils  to  be  complained  of  in  our  asylum  system 
arise  from  the  unwise  association  of  the  curable  with  chronic  cases.  This 
influence  has  an  injurious  effect  in  every  department  of  the  asylum,  as 
will  be  shown  by  the  following  summary  of  conclusions : — 

a.  That  the  system  of  mingling  curable  and  incurable  cases  of  insanity 


1885.]   Van  Bibber,  Intermediate  Hospitals  for  Mental  Diseases.  45 

is  a  most  injurious  one  to  those  patients  whose  condition  demands  the 
most  tender  consideration.  Not  only  is  this  true  from  a  medical  point  of 
view,  but  also  from  a  moral  and  social  aspect,  for  this  combination  pre- 
cludes the  proper  treatment  of  curable  cases,  adds  a  heavy  burden  to  the 
unfortunate  patient,  and  renders  him  open  in  after  years  to  the  ignorant 
judgment  of  society. 

b.  That  the  mingling  of  curable  and  incurable  insane  is  a  most  disas- 
trous combination  to  the  physician  of  the  institution,  for  this  system 
makes  innumerable  duties  which  wean  him  from  the  higher  ambitions  of  his 
profession  and  drag  him  inevitably  into  a  routine  and  unscientific  practice. 
That  the  large  percentage  of  chronic  cases  in  all  asylums  leads  the  physi- 
cian unconsciously  into  many  errors  concerning  the  management  of  the 
curable  insane,  and  his  duties  are  so  heavy  and  onerous  in  regard  to  the 
fiscal  and  household  management  of  his  institution  that  the  medical  and 
most  important  part  of  his  duties  are  necessarily  neglected. 

c.  The  mingling  of  curable  and  incurable  insane  has  a  most  enervating 
and  pernicious  influence  on  the  nurses  and  attendants  of  insane  asylums, 
it  blunts  their  efficiency  for  acute  and  important  cases,  and  becoming  too 
familiar  with  chronic  patients,  requiring  little  attention,  they  neglect  and 
fail  to  do  their  duty  to  cases  requiring  the  most  scrupulous  care  and  atten- 
tive nursing. 

d.  The  mingling  of  curable  and  incurable  insane  produces  an  erroneous 
and  injurious  effect  on  the  public  at  large,  for  it  helps  to  foster  the  idea  that 
insanity  is  a  disgrace,  that  it  is  unlike  other  diseases,  a  something  to  be 
hidden  away,  and  not  to  be  spoken  of  or  acknowledged. 

In  regard  to  the  correctness  of  these  conclusions  there  can  be  but  little 
doubt,  for  having  been  placed  in  a  position  to  take  a  broad  and  liberal  view 
of  the  treatment  of  the  insane,  I  am  forced  to  say  that  there  are  few 
places  either  in  this  country  or  in  Europe  where  an  acute  case  of  insanity 
is  given  the  same  advantages  of  treatment  as  are  furnished  to  other  diseases. 
This  conclusion  has  been  framed  upon  observation  and  experience,  not 
of  local  acquisition,  but  strengthened  by  the  knowledge  of  other  countries 
and  the  opinions  of  their  best  men.  If  the  proper  treatment  of  insanity 
shows  such  a  universal  deficiency  it  must  have  a  cause  which  is  equally 
widespread,  and  this  can  be  found  in  the  system  which  has  promoted  large 
institutions,  has  allowed  the  pernicious  crowding  together  of  acute  and 
chronic  cases,  and  has  developed  the  characteristic  formation  of  the  medi- 
cal staff  of  the  present  asylum.  If  psychology  is  to  advance,  it  must  do  it 
beyond  the  bad  influences  of  these  objectionable  features,  and  this  can 
only  be  accomplished  by  an  entire  change  in  the  plan  of  treatment  and 
administration  of  asylums. 

It  is  thus  that  I  have  been  led  to  consider  the  great  good  to  be  accom- 
plished by  the  establishment  of  small  hospitals  for  curable  cases  of  insan- 
ity, in  which  the  administrative  cares  would  be  assumed  by  an  officer 


46      Van  Bibber,  Intermediate  Hospitals  for  Mental  Diseases.  [Jan. 

appointed  for  that  purpose,  and  where  the  medical  head  of  the  institution 
would  have  only  his  professional  duties  to  occupy  his  time.  This  is  the 
intermediate  hospital  which  is  to  stand  between  acute  insanity  and  the 
asylum.  This  is  the  hospital  which  is  to  develop  the  ambition  of  the  spe- 
cialist, which  is  to  enlarge  his  horizon,  and  to  bring  him  out  of  an  asylum 
into  the  active  world  of  thought  and  progress.  This  is  the  hospital  which 
is  to  teach  the  treatment  of  insanity  as  it  has  not  yet  been  taught,  and  to 
educate,  under  active  clinical  instruction,  the  men  who  are  to  be  the 
guardians  and  promoters  of  a  most  important  reform.  The  possibility  of 
making  a  hospital  and  a  school  out  of  what  has  been  heretofore  an  asylum 
without  educational  power,  or  without  the  means  of  using  valuable  clinical 
material  is  a  proud  future  to  look  forward  to.  It  means  much  to  the  pro- 
fession. It  is  of  deep  significance  to  the  public.  It  means  an  assurance 
that  patients  confided  to  the  care  of  the  intermediate  hospital  are  to  have 
every  advantage  of  active  treatment  and  good  nursing.  It  means  a  course 
of  treatment  which  will  divert  and  distract  the  patients  as  much  as  possi- 
ble from  their  sufferings,  forcing  them  by  activity  to  brood  as  littte  as 
possible  over  the  dreary  melancholy  of  their  disease.  It  means  the  exclu- 
sion of  every  factor  that  can  militate  against  the  recovery  of  a  patient,  and 
the  least  possible  detention  after  recovery. 

The  intermediate  hospital  organized  to  enter  this  new  career,  with  a 
visiting  physician  whose  sole  duty  will  be  to  treat  his  patients,  with  a 
well  qualified  clinical  staff,  and  equipped  with  all  the  necessary  means  of 
treatment,  cannot  fail  to  change  very  materially  the  low  percentage  of 
recovery  from  insanity.  The  details  of  the  treatment  of  insanity  more 
than  any  other  disease  are  numerous  and  exacting.  The  subtle  action  of 
the  brain  must  be  reached  by  every  possible  means  of  assailing  it,  and 
hence  the  hygiene  of  the  patient  requires  much  care  and  intelligent 
supervision.  For  though  drugs  may  play  an  important  part  in  treatment, 
yet  in  many  phases  of  mental  trouble  the  physical  forces  need  to  be  stimu- 
lated by  every  possible  means,  by  bathing,  rubbing,  lotions,  by  walking, 
working,  and  generous  diet. 

It  is  difficult  to  draw  the  line  between  actual  insanity,  and  some  acute 
nervous  disorders,  and  heretofore  many  cases  have  been  consigned  to  an 
asylum  for  treatment  which  were  entirely  out  of  place  in  its  associations 
or  under  its  care.  The  middle  ground  will  be  covered  by  the  proposed 
intermediate  hospitals.  Acute  cases  of  insanity,  and  hybrid  types  of  ner- 
vous disorder  can  be  treated  and  cured  without  the  unpleasant  remem- 
brance of  an  asylum,  and  without  the  injurious  results  which  sometimes 
follow  the  injudicious  incarceration  of  sensitive  patients. 

It  was  the  fear  of  these  bad  effects  of  asylum  treatment  which  led  some 
specialists  to  inaugurate  a  movement  against  the  methods  and  regulations 
now  prevalent  in  insane  asylums.  The  non-asylum  treatment  of  the 
insane  has  in  the  past  three  years  been  warmly  advocated  by  some 


1885.]   Van  Bibber,  Intermediate  Hospitals  for  Mental  Diseases.  47 


distinguished  medical  men,  who  have  recognized  the  urgent  need  for 
more  careful  treatment  than  can  be  obtained  in  these  institutions.  The 
subject  caused  a  disagreeable  and  protracted  controversy  which  was  prac- 
tically without  result,  except  to  call  attention  to  the  fact  that  the  whole 
system  of  insane  asylums,  as  at  present  managed,  was  faulty  and  ineffi- 
cient. If  it  is  possible  to  inaugurate  the  plan  of  intermediate  hospitals, 
the  whole  question  will  find  its  solution,  for  the  scope  and  purpose  of  these 
establishments  will  be  the  treatment  and  cure  of  disease,  and  the  agitation 
about  incarceration  and  neglect,  or  the  evil  effects  of  crowded  asylums 
can  no  longer  find  ground  for  existence. 

The  plan  of  intermediate  hospitals  need  not  interfere  materially  with 
the  asylums  which  are  already  established.  These  institutions  would 
gradually  lose  their  claim  to  the  care  of  acute  cases,  and  become  in  time 
homes  for  incurables,  idiots,  and  feeble-minded  patients.  But  it  must  not 
be  inferred,  from  what  has  been  said,  that  there  are  not  in  England  and 
on  the  continent  some  large  institutions  where  only  curable  cases  of  in- 
sanity are  received,  and  treated  for  a  limited  time.  Yet  these  establish- 
ments are  too  large.  They  are  crowded  and  they  do  not  in  their  staff,  or 
in  their  appointments,  reach  the  standard  suggested  in  the  plan  of  inter- 
mediate hospitals.  There  is  more  of  the  asylum  than  the  hospital  about 
their  management,  and  hence  they  at  once  oppose  a  barrier  to  the  success- 
ful treatment  of  many  cases. 

In  order  to  test  the  feeling  of  medical  men  who  are  known  to  be  inte- 
rested in  the  progress  of  insanity,  and  at  the  same  time  to  ask  their 
opinion  on  the  subject  of  the  proposed  intermediate  hospitals,  I  have  pre- 
pared the  following  questions : — 

a.  Do  you  think  the  establishment  of  intermediate  hospitals  for  acute 
mental  diseases,  viz.,  small  hospitals  organized  as  other  curative  hospitals 
are  for  active  treatment,  with  resident  and  daily  visiting  physician,  prac- 
tical and  likely  to  prove  advantageous  to  the  public  and  to  the  profession  ? 

b.  Do  you  think  this  system  would  tend  to  prevent  the  routine  and 
careless  practice  so  prevalent  in  institutions  for  the  insane,  or  tend  to 
rouse  new  interest  and  investigation  in  psychology  ? 

c.  Do  you  think  that  placing  insanity  on  the  same  clinical  footing  as 
other  diseases,  treating  it  actively,  having  it  nursed  under  the  best  possible 
conditions,  avoiding  the  unlimited  association  of  lunatics  for  the  patients, 
and  avoiding  the  unnecessary  and  onerous  duties  of  fiscal  management 
for  the  physician,  do  you  think  these  changes  would  tend  to  improve  the 
percentage  of  cures  in  mental  diseases  ? 

d.  Do  you  think  that  the  proposed  hospitals,  shorn  of  the  mystery  and 
usual  characteristics  of  insane  asylums,  would  tend  to  eradicate  the  popu- 
lar idea  of  a  social  stigma  being  associated  with  insanity? 

e.  Do  you  think  it  would  be  practical  to  advise  that  a  ward  or  depart- 
ment for  insanity  be  established  in  large  clinical  hospitals  connected  with 


48     Van  Bibber,  Intermediate  Hospitals  for  Mental  Diseases.  [Jan. 

medical  schools,  where  acute  insane  patients  might  be  received  for  a  short 
time,  and  where  the  clinical  instruction,  so  much  needed  in  this  branch 
of  medicine  might  be  given  ? 

The  unvarying  answer  to  these  questions  has  been  affirmative,  but  as  I 
do  not  wish  to  ask  any  one  to  share  the  responsibility  of  my  opinions,  I 
will  simply  say  that  these  interrogations  have  been  laid  before  some  of 
the  highest  authorities  on  insanity  in  England  and  on  the  continent,  and 
have  received  their  most  cordial  approval.  And  why  should  they  not  ? 
The  feeling  against  the  old  method  of  treating  the  insane  is  widespread, 
and  in  every  country  where  civilization  has  developed  its  intelligence  the 
men  who  are  in  a  position  to  know  the  want  of  progress  in  this  branch  of 
medicine,  must  be  in  sympathy  with  any  movement  in  the  interest  of 
improvement. 

In  speaking  to  one  of  the  highest  authorities  on  insanity  in  England, 
one  officially  connected  with  the  governmental  supervision  of  the  insane, 
I  remarked  that  I  was  sorry  to  see  so  little  interest  shown  by  the  medical 
officers  of  asylums  in  the  treatment  of  their  patients.    I  was  forcibly 
struck  by  his  answer,  which  was  so  uncomplimentary  that  I  should  prefer 
not  to  risk  it  in  print.    I  said  I  supposed  their  time  and  attention  were 
fully  occupied  by  the  duties  of  management  of  the  asylums.    "Yes,"  he 
said,  "  that  is  to  a  great  extent  the  reason.  In  one  of  the  best  public  asylums 
in  England,  the  superintendent  prides  himself  on  the  fact  that  he  has  so 
accurate  a  knowledge  of  all  the  details  of  the  asylum,  that  if  there  is  a  dis- 
charge or  a  death  in  the  institution,  he  will  expect  to  see  a  diminution  of 
four  ounces  of  meat  in  the  housekeeper's  account."    In  pursuing  the  con- 
versation further  I  found  that  my  informant  had  some  very  decided  ideas 
about  a  reform  in  English  asylums.  I  was  surprised  to  hear  from  him  that 
the  men  who,  in  England,  have  the  largest  clinical  experience  and  the 
greatest  knowledge  of  insanity  were  not  allowed  to  practise,  but  were  con- 
fined to  their  duties  in  the  country  asylums.    On  the  other  hand,  that  the 
men  who  have  private  asylums,  where  at  most  there  are  two  or  three 
admissions  during  the  year,  where  the  service  does  not  give  any  active 
clinical  experience,  that  these  physicians  were  the  consulting  authorities 
on  insanity  in  London.    "  These  gentlemen,"  said  my  informant,  "  decide 
on  important  cases  in  consultation,  and  as  proprietors  of  private  asylums, 
whatever  may  be  their  talent  and  knowledge,  they  are  biased  and  influ- 
enced by  their  own  interest.    They  are  the  keepers  of  boarding-houses, 
and  they  have  an  interest  which  is  unprofessional.    Their  asylums  are 
filled  with  chronic  patients,  and  the  practice  is  consequently  a  routine,  in 
most  cases,  for  the  physicians  and  the  patients.    Public  opinion  is  strongly 
against  these  private  asylums,  and  since  the  Weldon  trial  has  been  decided 
against  Dr.  Semple,  the  feeling  is  increased."    From  what  I  could  learn 
during  this  interview,  I  do  not  think  the  private  asylums  will  recover 
from  the  prejudice  which  has  been  developed  against  them.    And  if  this 


1885.]   Van  Bibber,  Intermediate  Hospitals  for  Mental  Diseases.  49 


be  true,  there  will  be  another  urgent  reason  why  in  England  the  system  of 
intermediate  hospitals  should  be  inaugurated  as  soon  as  possible. 

But  in  whatever  country  this  progressive  step  finds  favor,  the  low  per- 
centage of  recovery  from  insanity,  so  universal  and  so  discouraging,  will 
undoubtedly  be  materially  improved.  The  reason  for  the  unfortunate 
result  of  treatment  may  be  the  combination  of  many  adverse  circumstances, 
but  it  is  not  to  be  entirely  attributed  to  the  fact  that  mental  diseases  are 
difficult  to  treat,  or  that  they  are  in  many  cases  incurable.  This  new 
organization  will  make  an  opportunity  for  both  physicians  and  patients, 
and  there  can  be  but  little  doubt  that  the  more  successful  treatment  of 
insanity  will  follow  its  adoption.  This  result  will  open  the  eyes  of  the 
profession  and  the  public,  and  will  force  a  more  considerate  legislation  in 
regard  to  our  lunacy  laws.  Heretofore,  these  enactments  have  been 
based  entirely  upon  the  protection  of  society  and  the  prevention  of  illegal 
detention  in  asylums.  The  time  has  now  come  when  the  interests  of  the 
patients  should  be  considered,  and  the  question  of  recovery  regarded  as  of 
most  paramount  importance.  The  advancement  of  psychological  science 
will  demand  increased  facilities  for  the  treatment  of  mental  diseases,  and 
the  historian  of  the  future  will  wonder  how  this  vital  aspect  of  the  ques- 
tion was  so  long  and  seriously  neglected. 

It  seems  almost  unnecessary  to  allude  to  the  vast  difference  which  exists 
between  the  legal  requirements  for  the  certification  of  an  insane  patient 
in  England  or  on  the  continent,  and  the  lax  regulations  about  the  same 
process  in  many  parts  of  this  country.  That  some  wiser  and  more  strin- 
gent laws  will  before  long  be  enacted' in  the  respective  States  upon  this 
subject  there  can  be  no  doubt,  for  experience  has  proved  that  insanity 
needs  the  fullest  protection  which  the  law  can  give,  and  up  to  this  time 
the  form  of  a  certificate  has  been  in  many  States  nominal  and  unsatisfac- 
tory. 

Notwithstanding  all  the  control  which  the  government  assumes  over 
insanity  in  England,  we  find  in  the  daily  press  during  the  past  summer 
the  most  violent  articles  on  the  tyranny  and  incompetence  of  asylum  phy- 
sicians, and  a  general  assault  on  the  whole  question  of  insanity  in  regard 
to  its  management  and  treatment.  The  Welden  case  brought  the  matter 
into  prominence,  and  after  the  verdict  against  Dr.  Semple  the  .public 
press  was  not  very  charitable  in  its  criticism  and  remarks.  As  an  ex- 
ample of  these  criticisms,  I  find  the  following  paragraph  in  a  July  number 
of  the  London  Truth. 

"  I  would  suggest  to  the  Commissioners  of  Lunacy  that  an  inquiry  be  made 
into  the  mental  condition  of  the  44  persons  who  have  been  put  in  the  asylum  of 
Dr.  Forbes  Winslow  on  Dr.  Semple' s  certificate,  for  it  is  fully  clear  that  this 
practitioner  entertains  views  concerning  insanity  which  would  lead  to  the  con- 
finement of  a  good  many  of  us." 

If  the  certification  of  insanity  in  England  can  be  criticized,  and  the 
protection  against  illegal  confinement  in  asylums  so  decidedly  doubted, 
No.  CLXXVII  Jan.  1885.  4 


50     Van  Bibber,  Intermediate  Hospitals  for  Mental  Diseases.  [Jan. 

I  confess  I  feel  some  curiosity  to  know  what  these  critics  would  think  of 
the  protection  which  the  law  offers  to  lunatics  in  nearly  every  part  of  the 
United  States.  It  would  be  clearly  impossible  to  give  more  than  a  hasty 
glance  at  this  side  of  the  subject,  for  every  State  has  a  different  form  of 
procedure.  For  an  example  of  this  easy  method  of  certification,  it  will 
be  only  necessary  to  look  at  the  superficial  way.  in  which  insane  patients 
are  committed  to  the  care  of  insane  asylums,  in  the  State  of  Maryland. 
I  copy  the  form  used. 

Medical  certificate  date. 

We,  the  undersigned,  Practising  Physicians  of  ,  do  hereby  certify 

that  is  insane  and  should  be  placed  in  a  hospital  for  the  insane. 

 M.D. 

 M.D. 

This  is  simplicity  itself.  There  is  no  specification  of  delusions  or  of 
tendency  of  insanity,  or  of  peculiar  form  of  mental  trouble.  Under  the 
broad  and  general  term  of  insanity,  covering  like  charity,  a  multitude  of 
commission  and  omission,  the  unfortunate  patient  is  turned  into  a  large 
society  of  lunatics,  all  of  whom  have  entered  into  that  dreary  abode  by 
the  same  broad  and  liberal  avenue. 

Now  whatever  may  be  the  defects  of  the  system  of  caring  for  the  insane 
in  England  or  on  the  continent,  we  must  acknowledge  that  the  entrance 
into  an  asylum  in  those  countries  is  made  narrow  and  hard.  In  England 
it  is  necessary  to  have  the  separate  certificate  of  two  physicians,  who 
must  examine  the  patients  separately  and  write  separate  certificates 
stating :  1st.  Qualifications  entitling  the  person  certifying  to  practise  as 
a  physician.  2d.  Facts  indicating  insanity  as  observed  by  the  examiner. 
3d.  Facts  indicating  insanity  communicated  by  others.  This  is  further 
strengthened  by  statement  of  relative  or  guardian  answering  seventeen 
questions.  These  certificates  are  required  to  be  sent  by  the  superintendent 
of  the  asylum,  together  with  his  official  notice  of  the  reception  of  the 
patient  to  the  commissioners  in  lunacy  within  "  one  clear  day"  of  the 
patient's  admission ;  and  yet  the  public  are  not  satisfied  that  patients 
alleged  to  be  insane  are  fully  and  satisfactorily  protected. 

In  order  to  guard  against  unjust  and  illegal  detentions  in  insane  asylums, 
the  government  of  each  State  should  make  stringent  laws,  and  surround 
the  admission  of  a  patient  into  an  asylum  with  as  many  safeguards  as 
possible.  Yet  there  should  be  ample  and  easy  provisions  made  for  imme- 
diate and  undelayed  treatment  of  mental  cases,  just  as  there  is  accommo- 
dation provided  for  other  acute  cases  of  disease.  This  want  would  be 
provided  for  in  the  plan  of  intermediate  hospitals,  where  the  patients 
could  be  received  without  legal  certification  for  a  limited  number  of  days, 
and  where,  being  under  the  treatment  of  a  visiting  physician  and  being 


1885.]   Van  Bibber,  Intermediate  Hospitals  for  Mental  Diseases.  51 

free  from  the  circumstance  and  unpleasant  surroundings  of  a  large  insane 
asylum,  being,  in  fact,  in  a  hospital  for  treatment  rather  than  detention, 
the  patient  could  suifer  no  wrong  while  the  proper  papers  were  obtained 
and  formalities  gone  through  with.  The  wisest  legislation  would  be  to 
make  the  admission  into  an  intermediate  hospital  the  first  and  necessary 
step  to  the  asylum,  and  require  that  one  certificate  should  be  signed  by 
the  physician  of  that  institution,  who  from  his  position  and  experience 
would  be  the  highest  authority  on  the  subject. 

The  plan  proposed  would  be  as  follows  :  That  though  it  is  essential  for 
patients  suffering  from  mental  diseases  to  be  protected  fully  by  exacting 
legal  formalities,  yet  it  is  not  wise  that  these  necessary  steps  should  inter- 
fere with  proper  and  immediate  treatment ;  hence,  it  should  be  made 
possible  to  admit  a  patient  to  an  intermediate  hospital  without  certifica- 
tion, under  the  condition  that  the  legal  requirements  be  carried  out  within 
a  certain  number  of  days ;  and  if  the  patient  at  the  end  of  a  specified 
time  prove  to  be  a  chronic  or  incurable  case,  that  he  should  be  removed 
to  an  asylum,  but  only  upon  the  additional  detailed  certification  of  two 
physicians,  one  of  whom  should  be  the  chief  medical  officer  of  the  hospital. 
This  arrangement  would  be  the  best  possible  means  of  allaying  any  fear  of 
illegal  detention  in  an  asylum,  for  the  hospital  would  be  after  a  fashion, 
a  clearing  house,  where  the  patients  entering  the  asylum  would  undergo 
a  searching  inspection  and  examination. 

These  are  the  general  outlines  of  a  system  which  I  am  confident  must 
in  time  take  the  place  of  the  present  imperfect  and  injurious  arrangements 
for  the  treatment  of  acute  insanity.  In  a  subsequent  article  I  will  enum- 
erate the  details  of  my  observations  in  this  country  and  in  Europe,  but  for 
the  present  it  is  enough  to  show  the  want  which  has  existed  so  long  and 
the  necessity  which  is  so  imperative,  and  to  suggest  the  means  to  supply 
the  one  and  successfully  carry  out  the  other.  It  will  not  require  much 
proof  to  make  good  the  assertions  made,  or  to  convert  any  one  but  a 
violent  partisan  from  the  imperfect  system  now  in  use,  to  the  adoption  of 
some  plan  for  the  amelioration  of  the  present  method  of  asylum  treatment. 
A  knowledge  of  insanity  certainly  precludes  the  idea  of  adhering  to  the 
injurious  crowding  of  asylums  and  the  consequent  meagre  and  unsatisfac- 
tory medical  treatment.  Self-interest,  however,  is  very  blinding,  and  it 
may  in  some  cases  lead  the  narrow-minded  to  overlook  the  broad  and 
scientific  side  of  this  question,  and  see  it  only  in  its  selfish  or  smaller  aspect. 
The  fact  of  being  insane  has  heretofore  been  considered  a  crime  against 
one's  family  and  society,  for  the  penalty  for  such  a  misfortune  has  in  most 
cases  been  imprisonment  for  an  indefinite  period,  the  duration  of  which 
has  been  up  to  this  time  dependent  on  many  extraneous  circumstances. 
But  in  the  system  of  intermediate  hospitals,  a  remedy  for  these  evils  is 
suggested,  which  will  not  only  give  every  possible  assurance  of  cure,  and 
the  shortest  duration  of  detention,  but  will  also  tend  to  reverse  the  iud^- 


52 


Shepherd,  Popliteal  Aneurism. 


[Jan. 


ment  of  the  public  and  give  insanity  its  proper  position  as  a  disease.  If 
there  were  no  other  reason  than  to  protect  the  patients  from  the  finger  of 
reproach  or  criticism  in  after  years,  this  system  would  have  an  ample 
argument  for  its  existence,  but  this  is  the  weakest  of  the  social  reasons  in 
favor  of  it,  while  the  medical  necessity  for  a  more  scientific  method  of 
treating  these  patients  is  of  an  urgency  that  no  partisan  can  deny. 

A  question  which  has  at  stake  the  restoring  of  the  wonderful  attributes 
of  the  brain  to  those  unfortunate  beings  who  have  lost  their  minds,  is  one 
which  must  interest  both  king  and  peasant,  both  the  highest  in  social  life 
and  the  humblest  laborer  in  the  land.  Still  more  must  it  be  of  vital  in- 
terest to  those  who  by  their  studies  learn  to  appreciate  fully  the  helpless- 
ness of  this  disease,  who  by  experience  have  found  out  how  sadly  its  treat- 
ment has  been  neglected,  and  who,  from  the  prospect  of  a  new  system, 
look  forward  with  hope  and  ambition  to  the  progress  of  the  future. 


Article  IV. 

An  Obscure  Case  of  Popliteal  Aneurism  which  simulated  Sarcoma. 
By  Francis  J.  Shepherd,  M.D.,  CM.,  Professor  of  Anatomy  McGill 
University  ;  Surgeon  to  the  Montreal  General  Hospital.1 

TV.  H.,  aged  46,  carpenter,  entered  the  Montreal  General  Hospital 
Dec.  81,  1883,  suffering  from  a  large  ulcer  of  the  right  leg,  and  a  tumor 
of  the  lower  and  back  part  of  the  right  thigh.  Previous  to  1875,  his 
health  had  been  always  good,  no  history  of  syphilis  or  rheumatism,  but 
has. had  frequent  attacks  of  gonorrhoea.  Has  been  intemperate  since  boy- 
hood. For  three  years  was  a  soldier  in  the  British  army.  In  the  autumn 
of  1875,  was  treated  in  the  Montreal  General  Hospital  for  double  popli- 
teal aneurism.2  The  aneurism  of  the  left  popliteal  was  treated  by  digital 
compression,  and  that  of  the  right  by  Carte's  compressors.  After  remain- 
ing in  hospital  two  months,  he  was  discharged  cured.  He  says  that  he 
kept  well  for  two  years,  then  the  small  hard  lump  which  had  remained 
in  his  right  popliteal  space  began  to  enlarge  and  pulsate,  and  was  again 
cured  by  compression.  For  the  next  four  or  five  years  he  was  not  troubled 
with  his  aneurisms,  but  about  a  year  and  a  half  ago  noticed  a  small  tumor 
in  the  right  popliteal  space;  this  tumor  was  hard,  firm,  and  did  not  pul- 
sate ;  it  gradually  increased  in  size,  and  when  he  was  in  hospital  a  year 
ago  for  treatment  of  the  ulcer  on  his  right  leg  it  was  noted  as  being  about 
the  size  of  a  man's  fist,  fixed,  hard,  and  without  pulsation.  From  this 
time  the  tumor  increased  more  rapidly. 

The  following  is  the  surgical  reporter's  account  of  his  condition  on 
entrance  :  "  On  examining  the  affected  leg  a  huge  indolent  ulcer  is  seen 
on  the  lower  and  outer  side  ;  there  is  also  a  large  tumor,  nearly  the  size 

1  Read  before  the  Canada  Medical  Association,  Aug.  1884. 

2  An  account  of  his  case  is  published  in  the  Canada  Med.  and  Surg.  Journ.,  vol.  i. 
p  298. 


1885.] 


Shepherd,  Popliteal  Aneurism. 


53 


of  a  man"?  head,  on  the  back  of  the  thigh ;  it  extends  from  the  popliteal 
space  to  the  middle  of  the  ham.  and  is  somewhat  egg-shaped.  The 
measurement  of  the  thigh  a  little  above  the  knee,  the  point  where  the 
circumference  is  greatest,  is  twenty-three  and  a  half  inches.  The  left 
limb  at  the  same  point  measures  twelve  and  a  half  inches.  The  tumor 
is  immovable,  smooth,  and  inelastic ;  it  gives  on  palpation  no  sense  of 
fluctuation,  neither  is  there  any  pulsation  in  it,  nor  is  any  thrill  felt  or 
bruit  heard.  Pressure  on  the  artery  above  does  not  influence  the  tumor. 
It  is  not  tender,  and  there  has  never  been  any  pain,  either  in  the  leg  or 
the  tumor,  except  after  long  standing ;  in  fact,  the  patient  thinks  very  little 
about  the  tumor,  and  comes  into  hospital  for  the  purpose  of  having  the 
ulcer  in  his  leg  treated.  The  leg,  owing  to  the  size  of  the  tumor  and  the 
stretching  of  the  tissues  over  it,  cannot  be  straightened  perfectly  or  flexed 
completely ;  he  lies  with  it  in  a  semiflexed  position.  Coursing  over  the 
tumor  are  numbers  of  enlarged  veins.  The  leg  is  not  swollen  or  oedema- 
tons.  The  glands  in  the  groin  are  enlarged,  and  can  be  felt  extending 
under  Poupart's  ligament  into  the  abdomen." 

Not  feeling  sure  as  to  the  diagnosis,  and  hesitating  from  the  history  to 
pronounce  it  a  sarcoma,  I  decided  to  watch  the  case  for  some  time  before 
undertaking  operative  procedures. 

After  the  patient  had  been  under  observation  some  three  weeks,  he 
complained  of  severe  pain  in  the  tumor  and  down  the  back  of  the  leg, 
and  it  was  found  that  the  measurement  at  the  point  of  greatest  circum- 
ference had  reached  twenty-four  and  a  half  inches.  He  now  began  to 
develop  febrile  symptoms,  and  for  several  weeks  his  temperature  was  a 
couple  of  degrees  above  normal,  his  tongue  was  coated  with  a  white  fur, 
and  there  was  some  tenderness  on  the  right  iliac  fossa.  When  he  re- 
covered from  this  slight  fever,  which  lasted  about  three  weeks,  and  which 
I  in  no  way  connected  with  the  tumor  of  the  leg,  a  consultation  of  my  col- 
leagues was  called.  The  tumor  had  all  this  time  been  slowly  increasing 
in  size,  the  man  could  now  only  very  slightly  either  flex  or  extend  his 
leg,  and  he  suffered  severely  from  pain. 

Although  fully  alive  to  the  possibility  of  the  case  being  one  of  aneurism, 
still,  from  the  total  absence  of  aneurismal  symptoms,  and  after  repeated 
and  careful  stethoscopic  and  manual  examinations,  I  was  becoming,  from 
week  to  week,  more  convinced  that  the  evidence  pointed  to  sarcoma, 
either  of  the  periosteum  or  the  parts  about  the  old  aneurism,  My  col- 
leagues agreed  with  me  in  this  conviction,  and  amputation  was  decided  on. 

The  man  having  readily  consented,  amputation  was  performed  on 
February  24,  1884,  at  the  junction  of  the  upper  with  the  middle  third  of 
the  thigh  and  well  above  the  tumor.  The  circular  method  was  employed, 
and  the  stump  was  dressed  with  iodoform,  gauze,  and  borated  cotton.  The 
wound  healed  rapidly,  and  at  the  end  of  two  weeks,  with  two  dressings, 
was  all  united  by  first  intention,  except  where  the  drainage  tubes  had  been. 

Examination  of  the  Tumor  On  cutting  into  the  tumor  it  had  to 

the  naked  eye  all  the  appearances  of  a  neoplasm,  but  on  examining  it 
microscopically  it  turned  out  to  be  composed  simply  of  fibrin.  The  fibrin 
was  not  deposited  in  layers  as  is  commonly  the  case,  but  solidified  "  en 
masse,"  so  to  speak.  There  was  no  cavity  in  the  tumor,  but  it  was  solid 
throughout.    The  femoral  artery  ended  above  the  tumor  in  a  blind  sac 


54 


Shepherd,  Popliteal  Aneurism. 


[Jan. 


(see  A  in  accompanying  Fig.).  Upon  slitting  up  the  popliteal  artery,  at 
the  lower  end  of  the  tumor,  the  external  coat  of  this  vessel  was  found  con- 
tinuous with  the  capsule  of  the 
tumor,  and  here  no  doubt  was  the 
orifice  of  the  aneurism  ;  about  this 
point  the  clot  was  in  a  softer  condi- 
tion than  in  other  parts  of  the  mass. 
The  sciatic  nerve  was  tightly 
stretched  over  the  tumor  and  con- 
siderably flattened.  Large  collate- 
ral branches  joined  the  popliteal 
artery  near  where  it  was  connected 
with  the  tumor  (see  accompanying 
Fig-)- 

The  diagnosis  of  popliteal  aneur- 
ism is  not  generally  a  matter  of 
great  difficulty,  still  some  of  the 
cases  of  aneurism  simulate  other 
diseases  so  closely  that  mistakes 
are  occasionally  made.  Many  able 
surgeons  have  opened  aneurisms 
supposing  them  to  be  abscesses,1  and 
others  again  have  tied  the  femoral 
artery  for  malignant  growths,  mis- 
taking them  for  aneurisms.  There 
are  not  a  few  cases  recorded  where 
an  old  consolidated  aneurism  has 
been  mistaken  for  a  sarcomatous 
tumor.  Dr.  Henry  B.  Sands  re- 
ported such  a  case  to  the  New 
York  Pathological  Society  (Med- 
ical  Record,  vol.  xxv.,  1877,  p.  188),  where  amputation  was  performed 
for  supposed  sarcoma  of  the  ham,  and  which  turned  out  to  be  a  consoli- 
dated aneurism.    The  case  is  as  follows : — 

"A  man  aged  46  entered  the  Roosevelt  Hospital,  suffering  from  a  tumor  of 
the  right  leg.  He  had  been  the  round  of  other  hospitals,  and  the  opinion  arrived 
at  was  that  the  patient  suffered  from  a  sarcomatous  tumor.  Treatment  by  com- 
pression had  been  practised  fourteen  years  previously,  for  supposed  popliteal 
aneurism.  This  was  continued  for  nine  weeks,  and  subsequently  another  tumor 
developed  below  the  site  of  the  original  one.  This  increased  from  year  to  year, 
by  an  annual  increment  of  an  inch  and  a  half  in  the  circumference  of  the  limb. 
Ten  days  before  admission  to  the  Roosevelt  Hospital  he  was  seized  with  a  rigor, 
and,  on  entering,  a  painful  tumor  on  the  leg  was  noticed,  which  extended  down 
from  the  popliteal  region.  A  careful  examination  was  deferred  for  four  days,  on 
account  of  the  depressed  state  of  the  patient.  It  was  then  found  that  the  tumor 
was  situated  on  the  posterior  and  upper  two- thirds  of  the  leg.    The  measure- 


A.  Femoral  artery  ending  above  the  tumor. 
P.  Popliteal  artery  continuous  with  the  sac  of 
the  tumor.  0.  Large  collateral  branch,  if. 
Sciatic  nerve. 


1  See  Dr.  S.  Smith's  "  Diagnosis  of  Abscess  from  Aneurism,"  Amer.  Jotjrn,  Med. 
Sci.,  April,  1873. 


1885.] 


Shepherd,  Popliteal  Aneurism. 


55 


ments  were  as  follows  :  Five  inches  above  the  ankle  the  circumference  was  five 
inches,  six  and  a  half  inches  above  the  ankle,  the  girth  was  nineteen  inches  ;  at 
the  upper  third  of  the  leg  the  measurement  was  twenty- three  and  a  half  inches. 
The  size  diminished  gradually  in  the  upward  direction.  The  tumor  was  firm, 
smooth,  and  nodulated.  That  portion  of  the  tumor  which  was  at  the  lower  part 
of  the  thigh  was  found  to  give  evidence  of  fluctuation  and  pulsation  ;  there  was 
also  a  bruit  heard  with  a  stethoscope.  On  December  18th,  the  mass  broke  in 
two  places,  and  discharged  a  large  amount  of  grumous  blood  together  with  solid 
masses  of  bloodclots.  Following  this,  there  was  a  subsidence  of  fluctuation  and 
pulsation.  Amputation  of  the  thigh  was  performed,  and  thirteen  days  after  the 
patient  died.  At  the  autopsy  it  was  found  that  the  tumor  was  an  aneurism.  At 
its  upper  part  there  was  a  solid  mass  which  was  at  first  thought  to  be  a  neoplasm, 
but,  on  more  thorough  examination,  proved  to  be  a  blood-clot.  The  popliteal 
artery  above  the  sac  was  obliterated,  and  it  was  a  mystery  how  pulsation  could 
be  accounted  for  without  communication  being  made  out  with  arterial  branches, 
and,  moreover,  without  the  mass  being  superimposed  on  the  artery." 

The  description  of  the  appearances  of  the  tumor  is  not  very  full;  no 
doubt  it  was  fed,  as  in  my  case,  by  anastomotic  branches,  which  joined 
the  popliteal  immediately  below  the  tumor.  The  existence  of  pulsation 
and  a  bruit,  with  fluctuation,  made  the  case  more  like  an  ordinary  aneurism 
than  my  own.  Its  points  of  resemblance  are  the  consolidated  tumor 
which  increased  in  size  the  former  cure  of  the  aneurism  by  compression, 
and  the  obliteration  of  the  artery  above  the  tumor. 

Mr.  Erichsen  (System  of  Surgery,  vol.  ii.  p.  22,  ed.  1869)  figures  a 
somewhat  similar  case  which  was  mistaken  for  a  painful  solid  tumor. 
The  leg  was  amputated,  and  the  tumor  proved  on  dissection  to  be  a  con- 
solidated aneurism  pressing  on  the  popliteal  nerve.  From  the  plate  of 
the  aneurism  which  is  given,  there  appears  to  be  a  large  cavity  near  the 
surface  of  the  tumor  which  contained  a  recent  coagulum,  and  which  must, 
during  life,  have  been  filled  with  fluid  blood. 

Mr.  Holmes,  in  his  article  on  aneurism  (Holmes's  System  of  Surgery, 
vol.  iii.  p.  43,  ed.  1883),  says : — 

"I  can  refer  to  at  least  three  cases,  one  a  preparation  in  the  St.  George's 
Hospital  Museum,  another  in  the  Museum  of  the  Royal  College  of  Surgeons, 
and  a  third  in  private,  in  which  the  limb  was  amputated  for  a  large  tumor 
in  the  popliteal  space,  believed  to  be  malignant,  and  which  turned  out  to  be 
cured  aneurism,  and  I  know  that  this  has  occurred  in  several  other  instances.  In 
some  of  the  cases,  however,  the  pressure  of  the  tumor  had  produced  gangrene, 
so  the  operation  was  necessary." 

Mr.  Prescott  Hewitt  (Medico- Ghirurg.  Trans.,  vol.  xxix.  p.  75)  relates 
an  interesting  case  of  aneurism  of  the  femoral  artery,  which  wras  cured 
by  ligature  of  the  external  iliac,  and  where,  after  all  pulsation  and  sound 
had  ceased  in  it,  the  tumor  gradually  increased  till  it  reached  the  size  of 
the  head  of  a  full-grown  foetus,  and  was  thought  by  many  of  the  surgeons 
to  be  a  tumor  of  a  malignant  character.  The  man  died  of  phthisis,  and 
the  post-mortem  examination  revealed  a  consolidated  aneurism  and  oblite- 
ration of  the  femoral  above  the  tumor. 

Mr.  Morrant  Baker,  in  an  article  on  "Aneurisms  which  do  not  Pulsate" 
(St.  Bartholomew's  Hospital  Hep.,  vol.  xv.  p.  79),  mentions  three  cases 


56 


Shepherd,  Popliteal  Aneurism. 


[Jan. 


where  the  leg  was  amputated  for  supposed  malignant  tumors,  which 
turned  out  to  be  consolidated  popliteal  aneurisms.  Two  of  these  cases 
were  referred  to  Mr.  Maunder  at  a  discussion  of  the  Clinical  Society 
{Lancet,  March  16,  1878). 

Dr.  Dunning  {Medical  Record,  August  5,  1876)  reports  a  case  of 
popliteal  aneurism  mistaken  for  semi-malignant  growth,  in  which  the 
surgeon  attempted  to  remove  the  tumor,  the  case  terminating  fatally  from 
hemorrhage  a  few  hours  after  the  operation.  In  this  case  the  tumor  was 
hard,  inelastic,  having  no  pulsation  or  bruit,  and  was  slowly  increasing  in 
size.  The  tumor,  as  examined  after  removal,  was  found  filled  with  con- 
centric layers  of  fibrin  occupying  its  entire  space,  save  a  small  cavity  in 
the  course  of  the  artery. 

Mr.  Oliver  Pemberton  {Lancet,  vol.  ii.  p.  120,  1877)  reports  a  case  of 
femoral  aneurism,  for  the  cure  of  which  he  tied  the  external  iliac.  The 
tumor  disappeared,  and  for  two  and  a  half  years  the  man  remained  per- 
fectly well,  when  suddenly  he  found  the  seat  of  the  aneurism  enlarging  to 
the  size  of  a  man's  fist.  It  continued  to  grow  slowly  till,  when  the  case 
was  reported,  it  measured  five  inches  in  length  and  breadth,  and  three  in 
depth.  It  was  free  from  pulsation  and  pain.  He  looked  upon  the  case 
"  as  an  instance  of  the  production  within  the  walls  of  an  apparently  cured 
aneurism  of  deposits  of  fibrin,  continually  increasing  in  amount,  always 
feeling  solid,  and  never  giving  rise  to  pulsation  or  sound."  He  mentions, 
shortly,  two  other  somewhat  similar  cases. 

These  cases  which  I  have  quoted  will  give  some  idea  how  difficult  may 
be  the  diagnosis  between  a  consolidated  aneurism  and  a  sarcomatous 
tumor.    PirogofF  says  r1 — 

"  If  I  were  asked  what  signs  I  hold  most  decisive  of  the  existence  of  an  aneu- 
rism which  does  not  pulsate,  I  must  confess  that,  if  there  is  no  bruit  to  be  heard 
at  any  part  of  the  tumor,  I  know  of  no  other  than  these  two:  (1),  collapse  of 
the  swelling,  sometimes  only  to  a  slight  extent,  when  the  main  artery  is  com- 
pressed between  the  heart  and  the  tumor ;  and  (2),  if  the  pulsation  of  the  artery 
can  be  felt  upon  the  surface  of  the  tumor,  an  unnatural  extension  of  its  impulse, 
for  example,  over  twice  the  usual  breadth  of  the  vessel.  But,  in  order  to  satisfy 
myself  of  these  two  phenomena,  it  is,  of  course,  necessary  to  examine  the  case 
repeatedly,  and  with  the  greatest  attention.  The  diagnosis  must  not  be  founded 
on  a  single  examination." 

Barwell  {International  Encyclopaedia  of  Surgery,  vol.  iii.  p.  398) 
"  does  not  know  of  any  positive  signs  by  which  to  distinguish  between  a 
solidified  aneurism  and  other  hard  tumors."  He  says,  "  the  great  aid  to 
diagnosis  will  be  the  more  or  less  globular  form  of  the  tumor,  its  isolation 
from  adjoining  structures,  and  the  fact  that  it  does  not  increase  (if  really 
solid)  but  rather  decreases."  Now  in  my  case  all  the  signs  by  which  a 
diagnosis  is  usually  made  were  wanting,  there  was  no  fluctuation,  pulsa- 
tion, bruit,  or  increased  arterial  impulse,  and  the  tumor  steadily  increased 


1  Klin.  Chir.,  quoted  by  Holmes,  St.  George's  Hosp.  Rep.,  vol.  vii.  1874. 


1885.] 


Shepherd,  Popliteal  Aneurism. 


57 


in  size.  The  history  of  the  case  certainly  pointed  to  aneurism,  but  the 
clinical  signs  did  not ;  in  fact,  there  was  not  a  single  symptom  which 
pointed  to  aneurism,  so  that  an  accurate  diagnosis  was,  in  my  opinion, 
impossible.  Had  a  diagnosis  of  consolidated  aneurism  been  made  out, 
could  any  other  means  besides  amputation  have  been  adopted  for  relief? 
I  think  not.  Ligature  of  the  superficial  femoral  above  the  tumor  would 
not  have  availed,  owing  to  the  obliteration  of  that  vessel.  Compression 
of  the  common  femoral  on  the  pubis  would  have  been  equally  useless,  as 
cutting  off  the  blood  from  this  source  had  been  practised  before,  and  the 
circulation  was  carried  on,  probably,  by  branches  of  the  internal  iliac 
artery  anastomosing  with  the  perforating  arteries  of  the  profunda  and 
articular  branches  of  the  popliteal.  Removal  of  an  aneurismal  tumor  by 
dissection  has  recently  been  successfully  practised  by  Mr.  Wm.  Rose, 
Surgeon  to  King's  College  Hospital,  London.  In  this  case  the  aneurism 
was  a  femoral  one,  and  Mr.  Rose  had  failed  to  cure  it  by  digital  com- 
pression, ligature  of  the  external  iliac,  or  rest  and  iodide  of  potassium,  so 
he  determined  to  dissect  out  the  tumor,  tying  all  the  communicating 
vessels  as  he  met  with  them.  The  aneurism  being  a  small  one,  only  the  size 
of  a  lemon,  the  operation  was  successfully  performed,  hemorrhage  being 
prevented  by  Esmarch's  bandage  and  Davy's  lever  {Lancet,  Dec.  22, 
1883).  In  my  case  this  method  of  treatment  would  have  offered  little 
chance  of  success,  owing  to  the  immense  size  of  the  tumor  and  the  already 
badly  nourished  condition  of  the  limb,  as  evidenced  by  the  large  indolent 
ulcer  of  the  leg,  So,  had  the  nature  of  the  tumor  been  certainly  diag- 
nosed, it  seems  to  me  that  amputation  would  have  been  the  most  suitable, 
and  probably  the  only  means,  by  which  the  patient  could  have  been 
relieved  from  his  sufferings  and  cured  of  his  disease. 

There  are  several  interesting  and  important  points  connected  with  the 
tumor  itself.  The  fibrin  was  not  arranged  in  layers  but  was  simply  one 
uniform  mass,1  and,  to  the  naked  eye,  looked  exactly  like  a  new  growth. 
The  orifice  of  the  aneurism  was  at  the  distal  end  of  the  tumor,  and  the 
blood  therefore  flowed  from  below  up,  with,  of  course,  a  lessened  stream ; 
the  circulation  owing  to  the  obliteration  of  the  femoral  above  the  tumor 
being  carried  on  by  collateral  branches.  As  there  was  no  cavity  in  the 
tumor  the  absence  of  pulsation  and  bruit  is  explained.  It  is,  however, 
difficult  to  understand  in  what  manner  the  tumor  increased  in  size,  and 
how  the  new  fibrin  was  deposited  ;  probably  the  mass  was  in  a  spongy 
condition  so  that  the  blood  could  easily  permeate  it,  and  thus  fibrin  could 
be  slowly  deposited. 

1  Mr.  Wagstaffe  (Path.  Soc.  Trans.,  vol.  xxix.  p.  73),  reports  a  case  of  popliteal 
aneurism  cured  by  Esmarch's  bandage,  in  which,  after  death,  he  found  the  clot  con- 
tained within  it  solidified  throughout  and  well  organized. 


58 


McNutt,  Double  Infantile  Spastic  Hemiplegia.  [Jan. 


Article  V. 

Double  Infantile  Spastic  Hemiplegia,1  with  the  Keport  of  a  Case. 
By  Sarah  J.  McNutt,  M.D.,  Lecturer  on  Children's  Diseases  in  the  New 
York  Post-Graduate  Medical  College,  and  Instructor  in  Gynaecology  in  the 
Woman's  Medical  College  of  the  New  York  Infirmary,  etc. 

Elsie  M.  died  of  pneumonia,  in  this  city,  November  12,  1883,  at  the 
age  of  two-and-one-half  years.  She  was  of  German  parentage,  and  born 
in  Dresden.  The  mother,  previous  to  her  marriage,  was  healthy.  Since 
then  she  had  been  poorly  nourished  and  overworked;  the  father  had  a 
chronic  bronchial  trouble,  yet  no  distinctly  tubercular  or  specific  family 
history  could  be  made  out  on  either  side.  Elsie  was  the  sixth  child.  The 
first  child  was  born  dead  on  account  of  a  "strain,"  which  was  followed  by 
flooding.  It  was  born  by  the  breach.  The  second  was  apparently  well- 
developed,  but  died  in  convulsions  the  twelfth  day  after  birth.  The  third 
was  a  girl,  who  is  still  living;  she  is  nine  years  of  age,  but  delicate,  with 
a  box-shaped  head  and  enlargement  of  the  epiphyses  of  the  long  bones. 
The  fourth  was  miscarried  at  the  end  of  six  months,  without  known  cause. 
The  fifth  lived  only  four  years ;  it  had  always  coughed,  and  died  after 
an  attack  of  measles.  During  her  sixth  pregnancy  the  mother  was  espe- 
cially miserable,  particularly  during  the  latter  half.  She  had  frequent 
attacks  of  fainting.  She  attributes  this  ill-health  to  a  tapeworm,  of  which 
she  passed  large  quantities  during  the  time.  The  delivery  of  the  child 
was  attempted  by  a  midwife,  but  it  presented  by  the  feet,  and  several  doc- 
tors were  called  in,  chloroform  was  administered,  and  the  head  delivered 
instrumentally.  The  mother  was  afterward  told  that  the  labor  was  so 
difficult  and  delayed  that  the  doctors  finally  despaired  of  saving  the  life  of  the 
child,  and  went  to  work  with  great  energy  in  order  to  save  her  own.  The 
child  had  convulsions  during  the  first  nine  days  of  its  life,  with  but  short 
intermissions.  Deglutition  was  from  the  first  difficult,  and  the  breathing 
always  was  noisy.  The  child  was  never  able  to  take  solid  food.  It  could 
cry  readily,  but  it  never  made  any  sound  as  if  trying  to  speak.  For  a 
long  time  it  did  not  appear  to  have  any  muscular  power,  but,  for  a  few 
months  preceding  its  death,  it  was  able  to  raise  its  head,  and  to  hold 
things  in  its  hands ;  its  grasp  was,  however,  uncertain. 

Elsie  was  presented  at  the  children's  clinic  of  the  Post-Graduate  Medi- 
cal School,  June  15,  1883.  I  therefore  had  her  under  observation  during 
five  months.  Upon  her  first  presentation  at  the  clinic  my  attention  was 
attracted  by  her  loud  and  stridulous  respiration,  and  I  started  toward  her, 
supposing  that  operative  interference  was  immediately  required.  The 
child  was  not  cyanosed,  however,  and  the  mother  told  me  that  the  breath- 
ing was  now  less  labored  than  it  had  formerly  been,  and  that  she  was  only 
anxious  to  have  something  done  to  induce  her  to  walk  and  to  talk. 

The  child  was  small  and  emaciated,  the  skin  wrinkled ;  there  was  very 
little  subcutaneous  fat,  and  the  muscles  and  bloodvessels  were  distinctly 
visible  under  the  integument.  The  head  was  asymmetrical,  the  bi-temporal 
being  the  longest  diameter,  whilst  the  right  temporal  region  was  the  most 
prominent.  The  child  resisted  examination,  screaming  and  kicking  vig- 
orously, and  striking  out  when  the  extremities  were  handled.  The  cry 
was  hoarse,  and  when  the  child  was  annoyed  the  respiration  was  particu- 

1  Thesis  presented  for  membership  in  the  American  Neurological  Association. 


1885.]        3IcXutt,  Double  Infantile  Spastic  Hemiplegia. 


59 


larly  labored.  The  respiration  was  of  the  forced,  costal  type  ;  the  inspi- 
ration prolonged,  high-pitched  and  noisy,  and  the  expiration  compara- 
tively easy.  The  superficial  veins  of  the  neck  were  distended  and  tor- 
tuous. The  thorax  was  flattened  antero-posteriorly  and  widened  laterally. 
The  percussion  resonance  was  good,  the  respiratory  murmur  low-pitched, 
and  air  entered  freely  into  the  lungs.  There  was  paresis  of  all  of  the 
extremities,  with  some  muscular  rigidity.  In  the  lower  extremities  both 
the  paresis  and  the  rigidity  were  more  marked.  The  legs  were  crossed. 
There  was  no  nutritive  disturbance  of  the  skin,  and  the  functions  of  the 
bladder  and  rectum  were  normal.  As  the  mother  fed  the  child  she  seized 
the  bottle  eagerly,  and  drank  rapidly  for  a  few  seconds,  to  be  then  inter- 
rupted by  the  regurgitation  of  a  portion  of  the  milk  through  the  nose,  ac- 
companied by  choking  and  struggling  for  breath.  Having  recovered,  she 
would  return  to  the  bottle  only  to  have  the  same  distressing  symptoms 
again  appear.  The  mother  said  that  she  was  then  feeding  better  than 
formerly,  when  swallowing  was  almost  impossible.  A  traumatic  or  hemor- 
rhagic injury  at  the  base  of  the  brain  was  suggested  to  me  by  the  associa- 
tion of  the  paralysis  with  this  dysphagia;  and  the  dyspnoea,  together  with 
the  feet  presentation,  the  traction,  and  the  circulatory  interference  im- 
plied by  the  prolonged  labor  and  the  instrumental  delivery. 

Upon  the  following  day,  the  patient  was  seen  by  me  with  Dr.  S.  M. 
Roberts,  Dr.  M.  P.  Jacobi,  the  professor  of  the  chair,  being  out  of  town. 
The  record  of  Dr.  Eoberts's  examination  was  as  follows  :  Head  asymme- 
trical, antero-posterior  diameter  shortened,  flattening  in  the  right  temporal 
region,  with  bulging  in  the  left  temporal,  extending  backward  ;  fulness 
in  the  right  occipital,  with  a  corresponding  flatness  in  the  left  and  a  sulcus 
to  the  left  of  the  median  line  in  the  occipital  bone  ;  the  margins  of  the 
occipitoparietal  suture  thickened,  also  those  of  the  inter-parietal  and  of 
the  fronto-parietal  sutures,  but  to  a  less  marked  degree  ;  the  fontanelles 
closed.  The  digits  semi-flexed  into  the  palm  of  the  hand,  the  fingers  over 
the  thumb ;  the  arms  and  forearms  in  a  position  approaching  extension 
and  pronation,  with  some  stiffness  of  the  muscles  which  could  be  readily 
overcome  ;  the  emaciation  of  the  lower  extremities  more  marked  than  that 
of  the  upper,  the  patellar  tendon  reflexes  somewhat  exaggerated ;  marked 
adduction  of  the  thighs,  the  legs  crossed  just  below  the  knees,  the  knees 
flexed  at  an  angle  of  about  90°  ;  feet  in  a  state  of  extreme  extension  on 
leg ;  toes  straight  ;  the  right  leg  extending  freely  upon  the  thigh  ;  the  left 
leg  also  extending,  but  less  freely ;  irritation  of  the  ham-string  muscles 
causing  contraction  of  the  quadriceps  extensor ;  all  the  contractures  being 
readily  overcome.  Although,  as  previously  stated,  the  patient  could  kick 
vigorously  when  annoyed  by  examination,  when  held  up  with  her  legs 
uncrossed,  both  limbs  would  be  strongly  adducted  and  extended,  all  of  the 
articulations  would  become  rigid,  the  tips  of  her  toes  only  would  touch  the 
floor,  and  no  effort  could  induce  her  to  make  any  voluntary  movement. 
There  was  no  muscular  tremor  either  in  the  upper  or  in  the  lower  extre- 
mities. The  child  heard  well,  and  could  recognize  individuals.  She 
would  smile  when  spoken  to  by  her  motherland  at  the  sight  of  food 
when  hungry ;  and  she  would  cry  when  a  stranger  approached  her ;  she 
could  not,  however,  be  called  bright. 

Dr.  Roberts  supported  my  diagnosis  of  injury  at  the  time  of  birth, 
emphasizing  particularly  the  evidence  afforded  by  the  sulcus  in  the  occi- 
pital bone,  and  suggesting  that  the  respiration  was  that  which  would 
occur  from  a  laryngeal  growth. 

On  June  29,  1883,  she  was  seen  by  Dr.  Amidon,  who  confirmed  the 


60 


McNutt,  Double  Infantile  Spastic  Hemiplegia.  [Jan. 


previous  examination,  but  substituted  a  diagnosis  of  chronic  hydrocephalus, 
with  descending  sclerosis  of  the  lateral  tracts. 

During  a  part  of  the  summer,  while  I  was  absent  from  the  city,  Dr. 
Amidon  kindly  attended  the  case.  Nothing  of  particular  interest  occurred 
during  this  interval. 

August  10,  on  my  return,  the  patient  Avas  presented,  with  a  tempe- 
rature of  101.5°  F.,  and  with  a  history  of  intestinal  catarrh.  These 
symptoms  were  relieved  by  treatment,  but  August  23,  the  mother  again 
returned,  saying,  that  for  three  or  four  days  the  patient  had  had  attacks, 
which  she  designated  as  "  cramps,"  having  four  or  five  in  the  course  of 
twenty-four  hours.  While  in  my  office  the  patient  had  one  of  these 
attacks,  it  lasted  five  seconds  ;  the  head  was  drawn  backward,  the  eyes 
were  staring,  and  moutli  open,  as  though  in  the  act  of  a  yawn.  The 
whole  body  was  rigid.  The  temperature  was  not  at  that  time  elevated, 
and  the  pulse  was  soft  and  slow. 

Sodii  bromidum  was  given,  and  on  September  10th  the  mother  reported 
that  the  convulsions  were  less  frequent  and  less  severe,  but  that  the  respi- 
ration was  more  than  usually  labored  when  the  patient  was  sitting  up. 
No  unusual  effort  was  apparent  when  sleeping  or  lying  down.  November 
3d  the  child  was  presented  at  the  clinic  in  its  usual  health.  On  the  10th 
its  temperature  was  found  to  be  102.5°  F.,  with  increased  pulse  and  respi- 
ration. It  had  a  gastro-intestinal  and  bronchial  catarrh.  Fine  rales  were 
present  all  over  the  chest,  excepting  at  the  left  apex,  where  the  signs  of 
consolidation  were  found. 

November  11th,  temperature  in  the  evening  105.2°  F.,  pulse  very  rapid 
and  compressible  ;  respiration  28.  The  alas  nasi  were  widely  dilated,  and 
the  respiration  was  very  labored.  The  child  had  frequent  spasms,  lasting 
four  to  five  seconds,  sometimes  would  only  appear  as  yawning,  and  again 
the  eyeballs  would  be  fixed  and  the  limbs  rigid.  It  sometimes  bit  its 
tongue.  12th,  9.30  A.  M.,  temperature  101°  ;  pulse  small  and  rapid, 
and  the  respiration  too  much  interfered  with  for  counting.  The  child 
would  appear  to  cry,  but  would  make  no  sound.  During  my  visit  four 
or  five  spasms  occurred  with  slight  intervals,  and  then  three  to  four 
minutes  would  intervene,  when  they  would  recommence.  There  was 
great  difficulty  in  giving  nourishment.  3  P.  M.  I  visited  the  child 
again  in  company  with  Dr.  S.  M.  Roberts.  The  temperature  was  then 
104°  F.,  and  the  pulse  was  rapid  and  weak.  The  respiration  was  hoarse 
and  wheezing,  with  accent  upon  the  beginning  of  expiration.  The  spasms 
were  being  constantly  repeated,  with  but  short  intervals  of  rest.  Upon 
the  onset  of  the  attack,  there  would  be  a  rapid  hoarse  inspiration,  fol- 
lowed by  a  prolonged  expiratory  effort.  There  appeared  to  be  spasm  of 
all  of  the  expiratory  muscles,  extending  to  all  the  voluntary  muscles, 
accompanied  by  opisthotonos.  The  eyes  were  fixed,  and  the  lower  maxilla 
was  retracted.  The  veins  of  the  neck  were  distended,  especially  upon  the 
left  side.  At  one  time  there  was  a  question  if  there  was  not  a  spasm  of 
the  inspiratory  muscles.  The  patient's  general  appearance  was  that  of  a 
child  straining  at  stool,  and  a  spasm  of  the  diaphragm  was  suggested. 
Pot.  bromid.  5  grs.  was  given  every  two  hours.  The  child  died  that 
night,  apparently  while  sleeping ;  the  convulsions  having  become  less  and 
less  marked. 

The  autopsy  was  made  by  Dr.  Amidon  upon  the  following  day. 
General  emaciation  was  present.    The  lower  extremities  were  in  a 
state  of  extreme  extension.    Length  of  body  30|  inches.    The  left  foot 


1885.]        McNutt,  Double  Infantile  Spastic  Hemiplegia. 


61 


was  adducted  and  lying  over  the  right ;  the  left  leg  was  f  inch  shorter 
than  the  right.  Length  of  the  right  lower  extremity  13§  inches,  with  a 
circumference  at  the  ankle  of  3  inches.  Length  of  the  left  lower  extre- 
mity 13  inches,  with  a  circumference  at  ankle  of  2|  inches.  Measure- 
ments of  the  upper  extremities  were  not  taken.  No  disturbance  in  the 
nutrition  of  the  skin  upon  any  part  of  the  body. 

Lungs  :  Signs  of  a  recent  broncho-pneumonia  upon  both  sides.  Heart : 
Abnormally  large ;  valves  normal;  walls  of  left  ventricle  thicker  than 
those  of  the  right,  in  proportion  of  four  to  one.  Liver  rather  large,  other- 
wise normal.  Kidneys  normal.  Spleen  normal.  Lungs  in  a  state  of 
broncho-pneumonia,  consolidation  at  both  apices,  most  marked  on  left 
side ;  hypostatic  congestion  at  base  posteriorly.  The  larynx  contained 
vegetations  which  involved  both  vocal  cords,  upon  the  right  side,  extend- 
ing to  the  anterior  commissure,  and  across  to  the  other  sides,  implicating 
both  ventricles,  and  making  the  surface  of  the  ventricular  folds  irregular 
and  puckered.  The  larynx  was  rather  small,  but  not  otherwise  abnormal. 
It  was  seen  by  Dr.  Elsberg,  who  thought  that  the  epiglottis  had  the  ap- 
pearance of  having  been  pendulous  during  life.  Dr.  Elsberg  made  a 
microscopical  examination  of  the  growth,  and  reported  that  the  apparent 
vegetations  were  composed  of  the  natural  tissue  of  the  part. 

The  head  was  sixteen  and  one-quarter  inches  in  circumference,  it  was 
asymmetrical,  the  bi-temporal  diameter  being  longer  than  the  fronto- 
occipital.  There  was  bulging  in  the  left,  and  flattening  in  the  right  tem- 
poral region.  A  bald  space  was  to  be  seen  a  little  to  the  right  of  the 
crown.  Upon  removing  the  integument,  fulness  was  to  be  found  also  in 
the  upper  angle  of  the  left  frontal,  extending  into  the  parietal  region  ;  a 
prominence  was  present  also  in  the  right  occipital  region.  The  inter- 
parietal and  the  fronto-parietal  sutures  were  marked.  The  occipito- 
parietal suture  was  better  united  than  the  others.  The  fontanelles  were 
completely  closed.  The  skull  was,  however,  very  thin,  especially  in  the. 
occipitoparietal  region.  Upon  removing  the  calvarium,  the  right  occi- 
pital fossa  was  found  to  be  considerably  larger  than  the  left.  More 
arachnoid  fluid  than  is  normal  was  found. 


Fig.  1. 


Left  hemisphere.  Atrophy  of  the  ascending  frontal  convolution  ;  atrophy  of  the  ascending 
parietal  convolution  ;  atrophy  of  the  paracentral  lobule,  and  possibly  atrophy  of  the  anterior 
part  of  the  first  temporal  convolution.    (About '%  actual  size.) 


62 


McNutt,  Double  Infantile  Spastic  Hemiplegia. 


[Jan. 


Fig.  2. 


Right  hemisphere.    Atrophy  of  the  ascending  frontal  convolution ;  atrophy  of  the  ascending 
parietal  convolution,  and  atrophy  of  the  paracentral  lobule.    (About  %.) 

There  was  everywhere  oedema  of  the  pia,  but  especially  in  the  fissure  of 
Rolando.  At  the  junction  of  these  fissures  with  the  longitudinal  fissure,  a 
large  collection  of  fluid  was  found  under  the  pia,  and  upon  its  evacuation 

atrophy  of  the  cortex  about  the 
3.  fissure  of  Rolando,  upon  both  sides 

was  disclosed.  The  veins  of  the 
pia  were  everywhere  distended  and 
tortuous. 

There  was  right  lateral  curvature 
of  the  spinal  column  in  the  dorso- 
lumbar  region.  Macroscopically  in 
the  cord  nothing  abnormal  was  to 
be  seen,  but  to  the  touch  it  seemed 
unusually  firm. 

Dr.  William  H.  Welsh,  who  ex- 
amined the  specimens,  sent  in  the 
following  report : — 

"  In  each  cerebral  hemisphere 
there  is  atrophy  of  the  paracentral 
lobule,  of  the  central  convolutions 
and  of  the  roots  of  the  three  frontal 
convolutions.  This  atrophy  is  some- 
what more  marked  in  the  right  than 
in  the  left  hemisphere. 

"  In  each  hemisphere  the  situa- 
tion of  the  central  convolutions  is 
occupied  by  a  sulcus,  the  margins  of 
which  are  the  adjacent  frontal  and 
parietal  convolutions.  In  this  sulcus 
can  be  seen  the  atrophied  central 
convolutions.    The  upper  two-thirds 


1885.]        McNuTT,  Double  Infantile  Spastic  Hemiplegia. 


63 


of  the  anterior  central  convolution,  is,  however,  not  readily  seen  upon 
the  right  side  without  drawing  apart  the  adjacent  posterior  central  and 
frontal  convolutions. 

"  The  atrophy  is  most  marked  in  the  paracentral  lobule,  the  anterior 
central  convolution  and  the  upper  two-thirds  of  the  posterior  central 
convolution.  The  lower  third  of  the  posterior  central  convolution  ap- 
proaches nearly  its  normal  size.  The  anterior  central  convolution  appears 
as  a  narrow  ridge  nearly  buried  from  sight  in  the  depths  of  the  sulcus. 
The  pars  opercularis  of  the  inferior  frontal  as  well  as  the  roots  of  the 
remaining  two  frontal  convolutions  are  distinctly  atrophied,  so  that  they  do 
not  appear  to  be  more  than  one-half  of  their  normal  size. 

"  The  length  of  the  sulcus  corresponding  to  the  central  convolutions  is 
7  ctm.  The  depression  corresponding  to  the  paracentral  lobule  is  1  cm.  in 
vertical  and  1^  cm.  in  antero-posterior  diameter. 

"  The  free  edge  of  the  right  anterior  central  convolution  measures  only 
1  mm.  in  diameter  in  its  upper  half,  and  2  to  3  mm.  in  its  lower  half.  The 
free  edge  of  the  posterior  central  convolution  measures  3  mm.  in  diameter 
in  its  upper  third,  4  mm.  in  its  middle  third,  and  10  mm.  in  its  lower  third. 

"The  right  cerebral  hemisphere  has  been  preserved  intact,  but  vertical 
sections  have  been  made  through  the  left  hemisphere  in  the  antero-posterior 
direction.  Upon  such  sections  the  situation  and  the  extent  of  the  atrophy 
can  well  be  seen,  although  it  will  be  remembered  that  the  atrophy  is  less 
in  this  than  in  the  right  hemisphere. 

u  Upon  a  vertical  antero-posterior  section  through  the  junction  of  the 
upper  with  the  middle  third  of  the  central  convolutions  (represented  in 
Fig.  4)  the  anterior  central  convolution 
(a,  c)  appears  extremely  atrophied  in 
the  depths  of  the  sulcus.  The  anterior 
margin  of  the  sulcus  in  this  situation  is 
the  second  frontal  convolution  (2  f)  and 
the  posterior  margin  is  the  posterior 
central  convolution  (p,  c),  also  atrophied, 
but  to  a  much  less  extent  than  the  ante- 
rior central  convolution.  These  margins 
nearly  meet,  so  that  from  the  free  sur- 
face of  the  brain  the  anterior  central 
convolution  is  hardly  visible. 

"  Upon  such  a  section  it  is  evident  that  the  atrophy  involves  especially 
that  part  of  the  central  cortex  which  is  adjacent  to  the  floor  and  the  sides 
of  the  praecentral  sulcus  and  the  sulcus  of  Rolando.  There  appears  to  be 
complete  absence  of  the  gray  matter  in  the  bottom  and  along  the  lower 
half  of  the  sides  of  these  sulci.  The  gray  matter  capping  the  top  of  the 
anterior  central  convolution  is  thinned,  but  it  can  be  distinguished.  The 
gray  matter  on  the  top  of  the  posterior  central  and  the  second  frontal 
convolutions  appears  to  be  nearly  intact  in  this  situation. 

"  In  the  situation  under  consideration,  the  anterior  central  convolution 
measures  8  mm.  in  vertical  diameter ;  its  transverse  (antero-posterior) 
diameter  in  the  depth  of  the  sulcus  is  barely  2  mm.,  while  near  the  free 
edge  where  the  cortex  appears  partly  preserved,  the  transverse  diameter 
is  5  mm.  Upon  vertical  section,  therefore,  the  anterior  central  convolu- 
tion is  shaped  something  like  a  mushroom,  there  being  a  somewhat  bulb- 
ous extremity  upon  a  narrow  stalk. 

"  That  part  of  the  posterior  central  convolution  which  makes  the  pos- 


Fig.  4. 


64 


McNutt,  Double  Infantile  Spastic  Hemiplegia. 


[Jan. 


terior  margin  of  the  sulcus  of  Rolando  is  atrophied  in  a  similar  way. 
The  posterior  central  convolution  is  much  less  atrophied  in  the  left  than 
in  the  right  hemisphere.  The  posterior  margin  of  the  second  frontal 
convolution  is  likewise  atrophied.  A  section  at  a  little  different  level 
shows  that  this  atrophy  involves  the  root  of  the  convolution. 

"  In  the  remainder  of  the  region  already  noted  as  the  seat  of  atrophy 
an  appearance  similar  to  that  described  can  be  observed.  The  atrophy 
affects  especially  the  gray  matter  immediately  adjacent  to  the  prascentral 
and  the  Rolandic  sulci. 

"  The  convolutions  other  than  those  mentioned  as  diseased  appear  of 
normal  size.  The  anterior  half  of  the  first  temporal  convolution  is  possibly 
a  little  smaller  than  normal.  The  convolutions  of  the  island  of  Reil 
appear  normal. 

"  Upon  microscopical  examination  it  is  found  that  the  cortex  in  the 
bottom  of  the  pra^central  and  Rolandic  sulci  is  replaced  by  a  finely  fibril- 
lated  tissues  rich  in  nuclei  and  in  corpora  amylacea.  This  rim  of  scle- 
rotic tissue  replacing  the  cortex  measures  about  -J  to  1  mm.  in  thickness. 
In  this  tissue  no  ganglion-cells  or  nerve-fibres  are  to  be  seen,  and  no  trace 
of  the  different  layers  of  the  cortex  can  be  made  out.  In  the  deeper 
parts  of  this  tissue  are  bloodvessels  surrounded  by  enormously  dilated 
perivascular  spaces  containing  lymphoid  cells,  large  fatty  granular  cells, 
corpora  amylacea,  and  in  some  places  extra vasated  red  blood-corpuscles. 

"  The  margin  of  sclerotic  tissue  can 
be  traced  up  for  a  certain  distance  along 
the  sides  of  the  anterior  central  convolu- 
tion and  then  there  appears  rather  ab- 
ruptly a  cortex  2  to  3  mm.  in  thickness, 
which  can  be  traced  over  the  top  of  the 
convolution  where  it  has  its  greatest 
thickness.  The  sclerotic  tissue,  however, 
does  not  disappear,  as  it  can  be  traced 
along  the  deeper  parts  of  this  cortex  near 
the  junction  of  white  and  gray  matter. 
At  the  top  of  the  anterior  central  con- 
volution can  be  made  out  in  normal  suc- 
cession, and  of  about  normal  thickness, 
the  molecular  layer,  the  layer  of  small 
and  the  layer  of  large  pyramids,  and 
then  comes  the  sclerotic  tissue  with  its 
abundant  nuclei,  fibrous  texture,  and 
dilated  lymph-spaces.  In  following  the 
cortex  down  the  sides  of  the  convolution 
it  is  seen  that  sclerosis  invades  from  the 
deeper  parts  more  and  more  of  the  cor- 
tex, the  layer  of  large  pyramids  first 
disappearing,  then  that  of  small  pyramids, 
while  the  molecular  layer,  although  ab- 
normally rich  in  nuclei,  can  be  traced 
all  of  the  way  down  the  sides  of  the 
convolution.  The  impression  is  not  that 
of  a  sclerosis  invading  the  cortex  from  the  surface,  but  rather  that  of 
invasion  from  the  deeper  layers  of  the  cortex  or  from  the  medullary 
substance. 


Section  through  anterior  central  con 
volution,  showing  atrophy  at  the  base 
(Magnified  ten  times.) 


1885.]        McNutt,  Double  Infantile  Spastic  Hemiplegia. 


65 


"  The  ray  of  white  substance  included  in  the  anterior  central  convolu- 
tion is  also  sclerosed.  Nerve-fibres,  if  they  exist  at  all  in  this  white 
substance,  are  naked  axis-cylinders.  In  place  of  the  medullary  substance 
is  a  finely  fibrillated  tissue,  rich  in  small  round  nuclei,  and  containing 
corpora  amylacea  and  dilated  perivascular  spaces.  This  sclerotic  tissue, 
although  similar  to  that  found  in  the  cortex,  is  less  dense  and  stains  less 
deeply  with  carmine. 

"  Giant  pyramidal  ganglion-cells  cannot  be  found,  even  in  the  gray 
matter  on  the  top  of  the  convolution  where  the  cortex  is  best  preserved. 
The  processes  of  the  ganglion-cells  of  the  third  layer  appear  shorter  and 
fewer  than  normal.  Still  the  ganglion-cells  can  be  distinctly  made  out, 
present  their  normal  triangular  shape  on  section,  and  appear  to  be  as 
abundant  as  usual. 

"  The  parts  of  the  posterior  central  and  of  the  frontal  convolutions, 
which  have  already  been  described  as  atrophied,  present  an  appearance 
similar  to  that  described.  In  the  bottom  of  the  Rolandic  and  prascentral 
sulci  the  cortex  has  entirely  disappeared  and  is  replaced  by  sclerotic  tis- 
sue ;  in  ascending  along  the  sides  of  these  sulci  the  cortex  begins  to 
appear,  first  as  the  molecular  layer,  then  the  layer  of  small  pyramids,  and 
at  the  top  of  these  convolutions  all  of  the  layers  can  be  made  out,  the  scle- 
rotic tissue  can  be  traced  as  described  along  the  deeper  parts  of  the  cortex  up 
to  the  summit  of  the  convolution  where  it  ceases.  The  sclerosis  invades 
also  the  white  matter  adjacent  to  the  atrophied  cortex. 

"  The  pia  mater  over  the  atrophied  parts  of  the  cortex  is  somewhat 
thicker  than  normal,  and  its  vessels  are  distended.  It  is  also  somewhat 
richer  in  cells  than  normal,  but  beyond  this  it  presents  no  marked  lesion. 


Fig.  6. 


Section  through  medulla. 


"  There  is  a  typical  bilateral  secondary  degeneration  of  the  pyramidal 
tracts.  The  parts  which  have  thus  far  been  examined  microscopically 
are  the  pons,  the  medulla  oblongata,  and  the  spinal  cord.  In  the  pons 
most  of  the  bundles  of  longitudinal  fibres  are  degenerated  ;  in  the  me- 
dulla oblongata  the  degeneration  is  confined  to  the  anterior  pyramids, 
which  to  the  naked  eye  appear  smaller  and  flattened.  In  the  spinal  cord 
the  degeneration  involves  the  pyramidal  tracts  in  the  anterior  and  in  the 
lateral  columns  of  both  sides.  The  situation  of  the  pyramidal  tracts  in 
the  pons,  medulla,  and  cord  is  occupied  by  a  finely  fibrillated  and  granular 
tissue  containing  some  naked  axis-cylinders,  but  very  few  medullated 
nerve-fibres.  The  tegumental  portion  of  the  pons,  all  of  the  medulla 
No.  CLXXVII  Jan.  1885.  5 


6G 


McNutt,  Double  Infantile  Spastic  Hemiplegia.  [Jan. 


oblongata  except  the  anterior  pyramids,  and  all  of  the  spinal  cord  except 
the  pyramidal  tracts  are  normal.  The  nuclei  of  the  hypoglossal,  the 
pneumogastric,  and  of  the  cranial  nerves  are  normal.  The  ganglion-cells 
of  the  anterior  horns  of  the  spinal  cord  are  normal  in  number,  size,  and 
general  appearance. 


Fig.  ?. 


Internal  aspect  of  right  hemisphere,  showing  the  atrophied  prascentral  lobule, 
with  the  atrophied  band  in  the  ccelosuni. 


"  There  is  atrophy  of  that  part  of  the  corpus  callosum  which  may  be 
considered  to  contain  the  commissural  fibres  of  the  two  motor  cortical 
areas.  A  short  distance  posterior  to  the  genu  the  corpus  callosum  is  very 
thin  for  a  distance  of  about  2  ctm.  It  then  becomes  abruptly  thick  and 
normal  again.  The  genu,  the  splenium,  and  the  posterior  half  of  the 
corpus  callosum  are  of  normal  thickness  and  contrast  markedly  with  the 
atrophied  portion. 

"No  lesion  has  been  found  in  any  parts  of  the  central  nervous  system 
other  than  those  described.  The  cerebellum  and  the  cerebral  convolu- 
tions, except  those  already  mentioned  as  atrophied,  are  normal  both 
macroscopically  and  microscopically  as  far  as  examined. 

"  The  disease  is  therefore  sclerosis  of  the  greater  part  of  the  motor- 
cortical  area  in  both  hemispheres,  with  secondary  descending  degeneration 
of  the  pyramidal  tracts." 

The  diagnosis  of  double  hemiplegia  has  been  given  to  this  case  because 
it  presented  the  lesion  of  infantile  spastic  hemiplegia  symmetrically  dis- 
tributed upon  both  sides  of  the  brain.  It  is  only  the  third,  or  at  the 
most  the  fourth  case  of  its  kind  which  we  have  found  upon  record.  Yet 
these  cases  do  not  appear  to  us  to  be  very  uncommon,  we  have  another  now 
under  our  care,  and  three  others  presenting  similar  symptoms  are  known 
to  be  now  in  the  city.  As  a  distinct  condition,  even  simple  infantile  spastic 
hemiplegia  has  but  lately  received  the  attention  of  text-books ;  Ziemssen's1 


1  Hitzig,  Ziemssen's  Cyclopaedia,  xii.  p.  124. 


1885.]        McNutt,  Double  Infantile  Spastic  Hemiplegia. 


67 


Cyclopaedia  mentions  it  in  a  foot-note  ;  Ross1  mentions  it,  citing  a  num- 
ber of  cases,  and  StrumpelP  refers  to  it,  but  not  fully.  No  widespread 
interest  has  been  excited  in  the  subject.  For  this  reason,  and  on  account 
of  our  own  mistaken  intra-vitam  diagnosis,  with  the  difficulty  which  we 
experienced  in  arriving  at  any  comprehensive  literature  of  the  subject, 
we  present  the  collection  of  facts  and  theories  which  follow.  As  a  treatise 
it  is,  and  in  the  present  state  of  the  subject  it  could  not  but  be  imperfect. 
If  it  should  merely  prove  suggestive  to  further  study  of  this  interesting 
condition,  it  will  have  served  its  purpose. 

History  Infantile  spastic  hemiplegia  is  the  clinical  designation  of  a 

disease  which  has  been  many  times  described  under  other  terms.  As 
cerebral  agenesis,  Cazauvieilh,3  in  1827,  described  twelve  cases,  in  six  of 
which  autopsies  were  made.  Cazauvieilh  says,  that  the  condition  had 
been  previously  described,  and  quotes  Morgagni  as  having  recorded  a 
case.  Heschl,*  in  1859,  and  Kundrat,5  in  1882,  included  a  number-  of 
cases  with  hydrocephalic  and  microcephalic  cases  under  the  title  of  poren- 
cephalic defects.  Little,6  in  1862,  included  twelve  cases  in  over  fifty 
cases  reported,  as  the  spastic  rigidity  of  the  new-born.  As  cerebral  atro- 
phy, Henoch7  has  described  a  number  of  cases.  Also,  under  the  same 
title,  Steffen8  has  collected  and  described  cases.  Meigs  and  Pepper9  have 
described  several  cases  as  symptomatic  contraction  with  rigidity.  More 
recently  Renoy10  has  described  a  case  ;  and  still  more  recently,  during 
1884,  Lambl,11  Lachi,12  and  Bianchi13  have  described  cases  as  porencephalic 
defects.  Lambert  Ottu  has  described  a  case  as  unilateral  spasm  hemi- 
plegia and  aphasia  following  measles.  As  double  infantile  hemiplegia 
Jonathan  Hutchinson15  has  described  a  case  which  is  yet  alive. 

The  main  features  of  the  cases  having  autopsies  are  tabulated  below. 

1  Ross,  Diseases  of  the  Nervous  System,  ii.  450,  1883. 

2  Striimpell,  Lehrbuch  d.  spec.  Path.  u.  Ther.  d.  inner.  Krankheiten,  ii.  349, 1864. 

3  Cazauvieilh,  Arch.  Gen.  de  Med.,  xiv.  p.  5,  1827. 

*  Heschl,  Prag.  Vierteljahrschrift  f.  p.  Hkd.  1859.  i.  59. 

5  Kundrat,  Die  Porencephalic,  Graz,  1882. 

6  Little,  Obs.  Tr.  London,  iii.  1862. 

7  Henoch,  Dis.  Children  (Wood's  Library),  p.  108. 

8  Steffen,  Gerhardt's  Kinderkrankheiten,  xix.  p.  243. 

9  Meigs  and  Pepper,  Dis.  Children,  p.  593, 1882. 

w  Renoy,  Progres  Med.,  1879,  p.  769.    Bull,  de  Soc.  Anat.  de  Paris,  1881,  p.  740. 

11  Lambl.  Arch.  d.  Psych,  u.  Nervenheilkunde,  xv.  1,  p.  45,  1884. 

12  Lachi,  Riv.  Clinica,  Feb.  1884,  p.  152. 

13  Bianchi,  Abst'd  in  Jour,  of  Psych,  and  Neurology,  Nov.  1884. 

"  Ott,  Tr.  Phil.  Neurolog.  Soc,  J.  N.  &  M.  Dis.,  Apl.  1884,  p.  256. 
15  Hutchinson,  Tr.  Path.  Soc.  London,  1882,  xxxiii.  p.  27. 


68 


McNutt,  Double  Infantile  Spastic  Hemiplegia. 


[Jan. 


Cases  of  Infantile  Spastic  Hemiplegia. 


Sex 

.  j  Seizure. 


1  Heschl, 


2  Heschl, 


3  '  Brechet, 

4  Ma.sch.ede, 


5  Eogers, 


(5  Eogers, 
7  Hugel, 


M.    I    From  hirth 
26  yrs  left  extremi- 
I    ties  weak. 


Symptoms. 


Left  hemiplegia  ; 
contractures  ; 
speech  impaired. 


Autopsy. 


F.    !    Right  hemiplegia, 

7  yrs  i  with  coutrac- 

■  tares. 

F.    Eight  hemiplegia, 

3j  yrs  atrophy. 

F.    |    Left  hemiplegia. 

27  yrs 


When.  15  yrs 
41  yrs  unconscious 
3  weeks  ;  re- 
covered with 
paralysis  of 
left  leg  and 
arm. 

M.   j   Dates  from 
49  yrs  convulsions 
in  youth. 
Asphyxiated 
at  birth. 


Left  hemiplegia, 
with  atrophy. 


Central  segment  cen- 
trum ovale  with  con- 
volutions pertaining  to 
it  absent  on  right  side 
from  the  convexity  to 
the  fissure  of  Sylvius. 

Absence  of  ascending 
convolutions  left  hemi- 
sphere defective,  com- 
municates with  lateral 
ventricle  of  that  side. 

Left  hemisphere  defec- 
tive. 

Eight  parietal  bone  de- 
fective £  in.  behind  cor- 
onal suture,  tbe  opening 
3  in.  by  £  to  1  in.  Eight 
hemisphere  presents 
cavity  in  posterior  half. 
Walls  of  connective 
tissue  of  neighboring 
convolutions  rusty 
brown. 

Anterior  half  of  right 
hemisphere  atrophied. 


By  whom  re- 
ported and 
where. 

Kundrat, 
Die  Porence- 
phalic, 18S2. 


Kundrat, 
Die  Porence- 
phalic, 18S2. 


Kundrat, 
Die  Porence- 
phalic 1S82. 

Kundrat, 
Die  Porence- 
phalic, 1SS2. 


Kundrat, 
Die  Porence- 
phalic, 1SS2. 


F. 

5  yrs 


S    Brodowski.|  F. 

12  yrs 


9  Kundrat, 


10  Kundrat, 


11  Sperling, 


12  Cazauvieilh 


13  Cazauvieilh 

I 


14  Cazauvieilh 


15  Cazauvieilh 


M. 

15  mo 


1  year  before 
death. 


F.  Difficultlabor 
29  yrs 


F. 

59  yrs 


F. 

51  yrs 


F. 

42  yrs 


F. 
30  yrs 


Eight  hemiplegia,  Left  hemisphere  has  a  Kundrat, 
weak  minded.        cavity  connected  with  Die  Porence- 
ventricle.  ;  phalie,  1S82. 

Left  hemiplegia.    Eight  hemisphere  pre-  Kundrat, 
sents  an  excavation  in  Die  Porence- 
anteriorhalf  l£x2xf  in.   phalie-,  18t>2. 
Eight  hemiplegia,  Communication  between  Kundrat, 
fissure  of  Sylvius  and  DiePoreuce- 
veutricle.  Surrounding  phalie,  1882. 
convolutions  converge] 
into  this  cavity. 

Eight  hemisphere  atro-  Kundrat, 

phied,  especially  about  Die  Poreuce- 
!  fissure  of  Eolando.       1  phalie,  18S2. 
Atrophy  about  lower  f  Kundrat, 
fissure  of  Eolando;  DiePorence- 
right  more  affected      phalie,  1SS2. 
than  left.   Sulcus  com-| 
municates  with  lateral 
ventricle.  Septum  pel-; 
lucidum  absent. 

Depression   behiud  fis-  Kundrat, 
birth:  shortening  sure   of  Eolando,  in-  Die  Poreuce- 
j  of  the  arm  and   eluding  the  ascending   phalie,  1882. 
I  leg,  contractures  parietal  convolution;: 
of  hand  ;  iutelli-  cicatricial  tissue  and( 
:  gent,  was  a  pigment. 

chorister  ; 
Left  hemiplegia, 
;  conti  actures. 
sensibility  and 
intellect  not  im- 
paired. 

Eight  hemiplegia,  Convolutions  left  hemi-  Cazauvieilh, 
including  face  ;  sphere  less  developed  Arch.  Gen.  de 
right  mamma  un-  than    right;    intellect    Med.,  1827, 


strabismus, 
nystagmus. 


Left  hemiplegia, 
contractures. 

Double  hemiple- 
gia, idiocy. 


Heniiplesnc  at 


| 

Convolutions  of  right  Cazauvieilh, 
hemisphere  less  devel-  Arch.  Gen.  de 
oped  than  left.  I   Med.,  1827, 

xiv.  p.  5. 


obtuse. 
Eight  hemisphere  atro- 
phied. 


developed. 
Left  side  para- 
lyzed and  unde- 
veloped. 


Left  half  of  body; Left  hemisphere  defec- 

i  emaciated,  espe-i  tive. 
cially  leg :  mouth 
drawn   to  right 

i  side.    Epileptic  ; 

j  voracious  appe- 
tite ;  intellect  ob- 
tuse. 


xiv.  p.  5. 
Cazauvieilh, 
Arch.  Gen.  de 
Med.,  1S27, 
xiv.  p.  5. 
Cazauvieilh, 
Arch.  Gen.  de 
Med.,  1S27, 
xiv.  p.  5. 


1885.]        McNutt,  Double  Infantile  Spastic  Hemiplegia. 


09 


Cases  of  Infantile  Spastic  Hemiplegia  Continued. 


22 


2.3 


24 


25 


2(3 


Physician. 


Cazauvieilh 


Sex 
and 


F. 

6S  yrs 


Cazauvieilh  i  F. 

27  yrs 


Morgagni, 


Little, 


Gibb, 


Pullain, 


Bourne 
ville. 


Henoch, 


Henoch, 


Henoch, 


Henoch, 


27  i  Renoy, 


2S  Huebner, 


IS  yrs 


Still- 
born. 


F. 

S  yrs 


F. 

19  yrs 


F. 

12  yrs 


F. 

5  yrs 


6  yrs 


F. 


Seizure. 


From  birtb. 


Instrumental 

delivery ; 
mother  died. 


Mother  during 
pregnancy 
received  an 
accidental 
blow  on  ab- 
domen by  a 
board. 


At  16  months 
with  spasms 
of  right  ex- 
tremities. 


At  3  months 
convulsions, 
followed  by 
paralysis. 


Healthy  to  H 
years.  After 
carnage  acci- 
dentsnddenly 
paralvzed 
Healthy  to  6 
months,  then 
had  measles 
with  convul- 
sions 8  days 
followed  by 
general  mus- 
cular rigidity. 
From  convul- 


Symptoms. 


Autopsy. 


4  yrs  sions  at  birth 


2|  yrs  When  15 
i  months  had 
I  fever  with 
I  convulsions 
followed  by 
complete 
paralysis. 


No  voluntary 
movements;  right 
side  of  mouth 
drawn    to   left ; 
cou  tractures. 
Right  hemiplegia, 
with  atrophy. 


Hemiplegia. 


Right  hemiplegia, 
with  atrophy  and 
contractures. 


Rigid  contrac- 
tures of  joints  of 
limbs  of  left  side, 
without  breaking] 
tendons  could  not' 
be  extended. 

Atrophy  right  ex- 
tremities; intelli- 
gence small. 


Right  hemiplegia, 
atrophy. 


Right  hemiplegia, 
atrophy,  contrac- 
tures ;  speaks  in 
one  syllable  ;  in- 
tellect poor. 

Right  hemiplegia, 
atrophy,  contz-ac- 
tures. 

Left  hemiplegia ; 
destructive  tem- 
perament ; 
speech  impaired. 

Double  hemiple- 
gia; contractures; 
stuttering ;  imbe- 
cility. 


Left  hemiplegia, 
contractures,, 
strabismus  ; 
spoke  badly ;  in- 
telligence weak 

Double  hemiple- 
gia, contractures 
of  extremities  ; 
little  intelligence 
no  speech. 


In  posterior  part  of  left 
frontal  lobe,  a  cavity 
having  an  ''accidental" 
opening  into  the  ven- 
tricle. 

Left  frontal  lobe  less 
prominent  than  right. 


Atrophied   zone  from 
convexity  to  base,  in 
frontal  lobe, most  mark- 
ed in  medullary  sub- 
stance. 

Whole  left  hemisphere 
atrophied  ;  surface  of 
right  hemisphere  cica- 
trized with  remnant  of 
old  clot. 

Right  parietal  bone  ec- 
chymosed ;  remains  of 
old  clot  in  right  hemi- 
spheres above  ven- 
tricle. 


Left  hemisphere  smaller 
than  right. 


Atrophy  of  left  hemi- 
sphere especially  of 
ascending  frontal,  as- 
cending parietal,  para- 
central lobule,  and  1st 
frontal  convolution. 

Middle  upper  part  of 
left  hemisphere  occu- 
pied by  cyst ;  right  py- 
ramid I-  normal  size  ; 
hematoidin  crystals  in 
wall  of  cyst. 

All  convolutions  of  left 
hemisphere  small, 
rusty  brown  color  ;  pia 
adherent. 

Right  upper  frontal  con- 
volution atrophied, pos- 
teriorly, dense,  and 
white. 

1st  frontal  convolution 
on  both  sides  atrophied, 
also  2d  but  in  less  de- 
gree. Corpus  callosum, 
fornix,  and  septum  lu- 
cidum  atrophied. 


Atrophied  right  hemi- 
sphere especially  about 
fissure  of  Rolando, with 
secondary  degenerat'n 
of  pyramidal  tracts. 

Atrophy  of  both  ascend- 
ing convolutions  of  left 
hemisphere  with  ante- 
rior part  of  right  infe- 
rior parietal  lobule  ; 
right  lenticular  nucle- 
us. Anterior  half  of 
pons,  with  pyramidal 
tracts  in  it  destroyed. 
Embolus  found  in  right 
middle  cerebral  artery 
from  root  to  bifurcation 


By  whom  re- 
ported and 
where. 


Cazauvieilh, 
Arch.  Gen.  de 
Med.,  1827, 
xiv.  p.  5. 

Cazauvieilh, 
Arch.  Gen.  de 
Med  ,  1827, 
xiv.  p.  5. 
Cazauvieilh, 
Arch.  G6n.  de 
Med.,  1827, 
xiv.  p.  5. 

Little,  Trans. 
Obst.  Soc, 
London, 
1862 

Gibb,  Lancet, 
Nov.  13, 
1858. 


Steffen, 
Gerh  art's 
Hdb.  Kinder- 
krankheiten, 
xix.  p.  243. 
Steffen, 
Gerhart's 
Hdb.  Kinder- 
krankheiten, 
xix.  p.  243. 

Henoch, 
Hd.  f.  d  Kin- 
derkrankh., 
18S3,  p.  231. 


Henoch, 
Hd.  f.  d.  Kin- 
derkrankh., 
1883,  p.  231. 
Henoch. 
Hd  f.  d.  Kin- 
derkrankh., 
18S3,  p.  231. 

Henoch, 
Hd.  f.  d.  Kin- 
derkrankh., 
1883,  p.  231. 


Renoy, . 
Progres  Med. 
1879,  p.  769. 


Huebner, 
Berl.  klin. 
Wochschr., 
1882,  p.  737. 


McNutt,  Double  Infantile  Spastic  Hemiplegia. 

Cases  of  Infantile  Spastic  Hemiplegia  Concluded. 


[Jan. 


No. 

Physician. 

Sex 
and 
age. 

Seizure. 

29 

Suckling, 

30 

Ross, 

F. 

Congenital. 

2k  yrs 

•31 

F. 

12  yrs 

32 

Lachi, 

F. 

44  yrs 

33 

Bianclii, 

M. 

Convulsions 

73  yrs 

in  early  in- 

fancy. 

34 

McNutt, 

F. 

Feet  pre- 

2* yrs 

sented  ;  in- 

strumental 

delivery  ; 

convulsions 

for  9  days 

after  birth. 

Symptoms. 


Hemiplegia  con- 
tractures, atro- 
phy, epilepsy. 

Double  hemiple- 
gia ;  monosyl- 
labic speech. 


Right  hemiplegia, 
strabismus, 
mystagmus  ; 
intelligence 
good  ;  practised 
clairvoyance. 


Right  hemiplegia, 
with  weakness 
of  left  leg  ;  atro- 
phy and  contrac- 
tures. 

Right  hemiplegia, 
with  weakness 
of  left  leg  ;  atro- 
phy and  contrac 
tures. 


Double  hemiple- 
gia; contractures, 
dysphagia  and 
dyspnoea;  intel- 
ligence small. 


Autopsy. 


Atrophy  about  fissure  of 
Rolando. 

Sulcus  occupying  cen- 
tral convolutions  on 
both  sides  ;  bottom  sul- 
cus opened  into  lateral 
ventricle  ;  pyramids 
and  lateral  columns 
small.    No  cicatricial 
tissue.   Giant  cells  of 
third  layer  absent  in 
atrophied  part. 

Depression  in  left  hemi- 
sphere occupying  fis- 
sure of  Sylvius  ;  lower 
part  of  ascending  con- 
volution of  island  of 
Reil  and  anterior  part 
of  first  temporal  con- 
volution atrophied. 

Atrophy  about  anterior 
part  of  fissure  of  Syl- 
vius on  left  side  ;  bot- 
tom of  fissure  opens 
into  ventricle  ;  septum 
lucidum  absent. 

Deep  sulcus  occupying 
central  convolutions  of 
left  hemisphere,  com- 
municating with  ven- 
tricle. Similar  sulcus 
occupying  superior 
third  of  central  convo- 
lutions of  right  hemi- 
sphere. Paracentral  lo- 
bule not  affected.  No 
descending  degenera- 
tion. 

Atrophy  about  the  fis- 
sure of  Rolando  on  both 
sides.  Atrophy  affects 
most  the  base  of  convo- 
lution, giving  mush- 
room shape.  Descend- 
ing degeneration  of 
both  pyramidal  tracts. 
Atrophy  of  larynx  with 
puckering  of  mucous 
membrane  over  vocal 
cords. 


By  whom  r€ 
ported  and 
where. 


Suckling, 
3ir.Med.Ilev., 
18S3,  p.  55.  I 

Ross,  Dis. 
Nerv.  Syst., 
18S3,  vol.  ii. 
p.  480. 


Lambl,  Arch, 
d  Psych,  a. 
Nerveuheil- 
kunde. 


Lachi,  Rev. 
Cl'nical,  Feb. 
1884,  p.  152. 


Bianchi, 
Abst.  Am.  J. 
Neurol  and 
Psychiatry. 


McNutt, 
Amer.  Jour. 
Med.  Sci., 
Jan.  18S5. 


Pathology  From  the  foregoing  table  it  will  be  seen  that  each  of  these 

cases  presented  a  gross  defect,  of  the  cerebral  cortex  located  near  the 
fissure  of  Rolando.  The  older  writers  mention  it  with  some  indefiniteness 
as  atrophy  of  the  hemisphere,  atrophy  of  the  frontal  lobe  of  the  hemis- 
phere, atrophy  of  the  posterior  part  of  the  frontal  lobe  as  in  one  of 
Cazauvieilh's  cases,  or  as  an  atrophied  zone  of  the  frontal  lobe  as  in  Mor- 
gagni's  case.  The  more  recent  writers,  however,  locate  it  according  to  the 
modern  nomenclature  for  the  motor  area  of  the  brain.  Suckling's  case 
had  atrophy  about  the  fissure  of  Rolando.  Renoy's  case  had  atrophy  of 
the  right  hemisphere,  especially  about  the  fissure  of  Rolando.  Lambl's 
case  had  atrophy  of  the  lower  part  of  the  central  convolutions.  Bianchi's 
case  had  atrophy  of  the  central  convolutions  upon  both  sides.    This  was 


1885.]        McNutt,  Double  Infantile  Spastic  Hemiplegia. 


71 


also  true  of  Ross's  case  and  of  our  own.  When  the  atrophy  did  not  imme- 
diately border  the  fissure  of  Rolando,  it  was  in  a  neighboring  part ;  thus 
Henoch's  boy  had  atrophy  of  the  first  and  second  frontal  convolutions 
upon  both  sides,  and  in  Lachi's  and  Lambl's  cases  the  region  about  the 
anterior  part  of  the  fissure  of  Sylvius  was  affected. 

The  parietal  and  the  temporal  lobes  have  been  implicated  in  some  cases. 

The  cerebral  lesion  has,  as  a  rule,  the  appearance  of  an  excavation  of  the 
surface  of  the  hemisphere,  into  which  excavation  the  gray  matter  of  the 
cortex  dips.  Morgagni's  case  is  said  to  have  had  atrophy  especially  of 
the  medullary  portion  of  the  zone.  Of  our  own  case  Dr.  Welsh  remarks 
that  "the  impression  is  not  that  of  a  sclerosis  invading  the  cortex  from 
the  surface,  but  rather  that  of  invasion  from  the  deeper  layers  of  the 
cortex  or  from  the  medullary  substance."  Heschl  describes  the  atrophy 
in  one  of  his  cases  as  absence  of  the  centrum  ovale  pertaining  to  the  part. 

Openings  from  the  bottom  of  the  excavation  into  the  lateral  ventricle 
were  present  in  eight  of  our  thirty-two  cases.  Where  such  a  sinus 
occurred  the  surrounding  convolutions  usually  converged  toward  the  pit. 
On  account  of  the  sinus  these  cases  were  called  porencephalic  from  porus, 
a  passage,  but  as  the  sinus  with  the  convergence  of  the  convolutions  was 
considered  to  indicate  primitive  malformation,  porencephalic  came  to  be 
applied  to  all  supposed  congenital  defects.  Kundrat  applies  it  still  more 
widely  to  all  defects  of  which  absence  of  tissue  is  a  mark.  Atrophy  of 
the  corpus  callosum  was  present  in  Cases  26  and  34.  In  each  of  these 
cases  the  cortical  atrophy  extended  to  the  median  fissure.  Atrophy  or 
absence  of  the  septum  lucidum  is  mentioned  of  Cases  10,  26,  and  32.  In 
Cases  10  and  32,  the  lower  part  only  of  the  central  convolutions  was 
defective.  Not  many  microscopic  examinations  have  been  made.  Scle- 
rotic tissue  with  absence  of  the  proper  nerve  tissue  of  the  part,  charac- 
terized the  cortical  atrophy  at  the  base  of  the  convolutions  in  our  own 
case  ;  at  the  convexity  of  the  convolutions  also  the  processes  of  the  third 
layer  were  small.  An  absence  of  processes  was  characteristic  of  Bianchi's 
case,  and  in  Ross's  case  the  cortex  was  embryonal  in  type.  All  of  Hen- 
och's cases  showed  cicatrization  about  the  focal  lesion.  Secondary 
degeneration  was  present  in  Renoy's  case,  and  also  in  our  own.  In 
Bianchi's  case  and  in  Ross's  case  there  are  said  to  have  been  neither  cica- 
trical nor  sclerotic  tissue  to  be  found. 

Steffen1  says,  that  atrophy  of  the  brain  can  occur  either  from  an  arrest 
of  development  or  from  a  process  of  pathological  degeneration  in  an 
already  developed  part.  In  the  first  class  of  cases  the  color  of  the 
atrophied  part  is  less  bright  than  in  the  normal  condition,  approaching 
the  gray  red  tint  and  the  consistency  is  less.  The  arrest  of  development 
is  said  to  be  seen  in  the  persistency  of  low  forms,  and  in  the  more  or  less 


1  Steffen,  loc.  cit. 


72 


M  c  N  u  t  t  ,  Double  Infantile  Spastic  Hemiplegia. 


[Jan. 


considerable  number  of  naked  axis  cylinders,  while  in  the  material  for  the 
construction  of  their  medullary  sheath  are  to  be  found  masses  of  granular 
cells.  In  the  atrophy  which  results  from  a  degenerative  process,  on  the 
contrary,  the  atrophied  parts  are  more  or  less  dense,  gray-white,  and  have 
an  irregular  surface  showing  furrows  and  pits.  As  the  rule,  a  puckered 
cicatrix  forms,  and  the  surrounding  portion  of  the  cortex  undergoes  a 
diffused  sclerosis.  With  retraction,  the  motor  area  becomes  diminished 
in  size.  Thus  the  spastic  hemiplegia  of  infancy  is  sometimes  named  uni- 
lateral atrophy  of  the  brain.  The  fibres  of  the  pyramidal  tract  undergo  a 
descending  sclerosis,  and  consequently  the  anterior  pyramid  of  the  medulla 
on  the  side  of  the  lesion  is  usually  atrophied,  while  microscopic  examination 
of , the  cord  shows  sclerosis  of  the  lateral  column  of  the  opposite  side. 

Cazauvieilh's  observations  upon  this  disease  harmonize  more  perfectly 
with  modern  pathology  than  do  those  of  many  more  recent  writers. 
Cazauvieilh  described  cerebral  agenesis  as  having  its  origin  either  during 
infancy  or  during  intra-uterine  life,  the  resulting  defect  being  with  or 
without  a  tissue  change.  As  a  rule,  late  intra-  or  extra-uterine  arrest 
appears  to  be  accompanied  by  the  development  of  cicatricial  tissue  in  and 
about  the  atrophied  part. 

Symptoms — The  subjects  of  infantile  spastic  hemiplegia  may  live  to  old 
age.  Cazauvieilh's  cases  were  in  middle  life,  and  Bianchi's  case  was  73 
years  at  the  time  of  death.  The  inception  of  the  disease,  however,  always 
dates  back  to  early  childhood,  or  to  intra-uterine  life.  At  whatever  age 
seen,  its  victims  are  characterized  by  more  or  less  complete  hemiplegic 
motor  inability,  with  contractures  and  defective  development  of  both  bones 
and  muscles.  This  defective  development  is  called  atrophy.  It  is  not  atro- 
phy in  the  sense  of  a  retrogression,  as  the  faradic  reaction  never  is  lost. 
The  atrophy  and  paralysis  may  be  unilateral  or  bilateral.  In  the  bilateral 
affection  both  hemispheres  of  the  brain  have  presented  defects,  as  in  Cases 
10,  26,  28,  and  34.  The  paralysis  may  extend  to  the  face,  which  is  affected 
on  the  same  side.  Nystagmus  and  strabismus  were  present  in  Cases  8  and 
31.  In  both  of  these  cases  the  parts  about  the  anterior  portion  of  the  fissure 
of  Sylvius  were  defective. 

True  aphasia  may  be  present ;  monosyllabic  utterance  is  mentioned  for 
a  number  of  cases.  A  case  now  under  my  care  can  speak  a  two-syllable 
word  only  by  making  two  separate  efforts  at  its  articulation,  and  for  the 
second  syllable  he  requires  prompting.  Having  pronounced  the  first  he 
forgets  the  necessity  for  the  second.  Dr.  Ott's  case  pronounces  the  first 
syllable,  and  completes  his  remark  by  a  gesture  indicating  the  object 
required.  One  of  Ross's  cases,  also  one  of  Henoch's  cases,  had  mono- 
syllabic speech.  Of  one  of  Cazauvieilh's  cases,  which  lived  to  womanhood, 
it  is  said  that  she  spoke  but  seldom  and  in  an  abrupt  manner. 

Dysphagia  is  mentioned  of  a  number  of  cases.  The  peculiar  dyspnoea 
and  stridulous  respiration  exhibited  by  Elsie,  with  the  arrested  laryngeal 


1885.]        McNutt,  Double  Infantile  Spastic  Hemiplegia. 


73 


growth,  is  mentioned  only  by  Little,  and  by  him  simply  in  an  incidental 
way. 

Idiocy  may  or  may  not  be  present.  Lambl's  case  practised  clairvoy- 
ance, and  was  very  bright.  Ross  mentions  a  great  scholar  who  was  an 
infantile  hemiplegic.  Bichat  is  said  to  have  had  unilateral  atrophy  of  the 
brain.  Four  cases  of  double  hemiplegia  are  furnished  by  our  list,  two 
others  are  known  to  us  in  which  autopsy  has  not  been  made  ;  all  were 
imbecile. 

To  recapitulate  :  The  symptoms  of  infantile  spastic  hemiplegia  are 
hemiplegic  motor  inability,  atrophy,  and  contractures,  with  or  without 
aphasia,  monosyllabic  utterance,  dysphagia,  dyspnoea,  and  idiocy,  the 
latter  being  especially  characteristic  of  the  double  affection. 

Etiology — The  etiology  of  infantile  spastic  hemiplegia  has  been  defined 
as  primitive  defect,  arrest,  encephalitis,  and  hemorrhage. 

Clinically  the  cases  of  infantile  hemiplegia  may  be  divided  into  three 
classes,  those  in  which  the  inception  of  the  condition  precedes  birth,  those 
in  which  it  occurs  after  birth,  and  those  of  which  parturition  is  the  cause. 
In  the  first  class  of  cases  the  defect  has  been  considered  allied  to  the  defect 
of  microcephalic  and  anencephalic  brains.  Maternal  impressions,  a  lack 
of  formative  force,  primitive  abnormal  distribution  of  bloodvessels,  and  an 
abnormal  influence  of  the  sympathetic  nerve,  has  each  been  cited  for  its 
explanation.  Hervouet1  has  recently  claimed  that  not  even  apparent  scle- 
rosis opposes  the  theory  of  primitive  defect,  diagnosticating  that  circum- 
stance in  the  case  of  an  idiotic  child,  in  whom  the  whole  anterior  part  of 
the  brain  was  shrunken  and  hard.  Heschl,  on  the  contrary,  thought  that 
even  in  intra-uterine  cases  a  morbid  process,  as  meningitis  or  encephalitis, 
had  occurred.  Gibbs's  case  would  indicate  that  traumatism  with  hemor- 
rhage may,  even  during  intra-uterine  life,  be  one  of  its  factors.  This  case 
was  stillborn.  It  presented  hemiplegic  atrophy  with  contractures  which, 
without  cutting  the  tendons,  could  not  be  overcome.  The  opposite  parietal 
bone  was  ecchymosed,  and  the  hemisphere  under  it  presented  the  remains 
of  an  old  clot.  During  her  pregnancy  the  mother  had  received  a  severe 
blow  upon  the  abdomen. 

In  the  second  class  of  cases,  the  child,  previously  healthy,  is  seized  with 
fever  and  convulsions,  sometimes  during  or  after  an  acute  disease.  These 
symptoms  subside  to  give  place  to  hemiplegia  with  rigidity,  with  or  with- 
out the  implication  of  cerebral  nerves.  This  paralysis  gradually  disap- 
pears, or  it  does  not  disappear.  In  the  latter  case  the  paralyzed  part  ceases 
to  grow,  and  at  the  autopsy  atrophy  with  sclerosis  may  be  found  in  the  cere- 
bral motor  tract.  An  interesting  etiological  suggestion  has  been  made  for 
these  cases  by  Benedikt,  whom  I  find  quoted  by  Strumpell  :2  this  suggestion 
is,  that  the  spastic  hemiplegia  of  infancy  is  a  systematic  affection  of  the 


1  Hervouet,  Arch,  de  Phys.,  August  15, 1884. 


2  Strumpell,  1.  c. 


74 


McNutt,  Double  Infantile  Spastic  Hemiplegia. 


[Jan. 


motor  cerebral  cortex,  analogous  to  the  polio-myelitis  of  the  anterior  horns. 
He  compares  the  access  of  this  disease  with  the  access  of  polio-myelitis  in 
infants,  finding  the  prodromata  very  similar,  and  the  origin  of  each  equally 
obscure.  The  theory  is  alluring,  but,  on  the  other  hand,  these  hemiplegias 
have  been  particularly  associated  with  measles,  an  association  which  has 
suggested  intracranial  hemorrhage  even  for  them  from  the  blood  dyscrasia 
of  this  disease.  Also  it  will  be  remembered  that  in  Case  23  hrematoidin 
crystals  were  found  in  the  neighborhood  of  the  focal  lesion,  while  in  Case 
24  the  shrunken  convolutions  were  of  a  rusty  color.  Steiner1  considers 
cerebral  hemorrhage  in  the  course  of  the  acute  zymotic  disease  to  be  due 
to  fatty  degeneration  of  the  walls  of  the  vessels. 

For  the  third  class  of  cases,  Ross2  has  suggested  hemorrhage  from  an 
injury  during  the  process  of  birth.  In  this  theory  Ross  acknowledges  the 
priority  of  Little,  who,  in  1862,  had  advocated  hemorrhage  at  birth  as  a 
cause  for  the  spastic  rigidity  of  the  newly-born,  referring  this  condition,  in 
spite  of  his  autopsy,  to  a  spinal  origin.  Little  cited  sixty-three  cases,  in- 
cluding the  hemiplegia,  which  we  have  quoted,  together  with  eleven  other 
unilateral  and  bilateral  hemiplegias  in  which  autopsies  were  not  made.  In 
all  of  these  cases  abnormal  circumstances  attended  the  delivery.  One  was 
born  cyanosed,  and  had  convulsions  after  birth,  in  one  turning  was  per- 
formed, and  it  did  not  breathe  for  one-half  hour  ;  another  had  convul- 
sions for  forty-eight  hours  after  birth;  another  "lay  as  if  dead"  for  six 
weeks  after  birth  ;  another  had  the  cord  around  its  neck,  and  did  not 
breathe  for  ten  minutes  ;  another  was  a  foot  presentation,  and  was  insensi- 
ble for  two  hours  after  birth  ;  another  had  convulsions  for  two  days  after 
birth  ;  for  another  instruments  were  used,  and  the  child  was  restored  with 
difficulty  ;  another  was  asphyxiated  for  two  hours  after  birth  ;  another  was 
delivered  by  the  feet — it  did  not  cry  for  two  hours  ;  another  was  a  cross 
presentation,  and  was  delivered  by  instruments;  another  was  "black" 
when  born,  and  another  had  convulsions  during  three  days  after  birth. 

Ross  states  that  in  a  number  of  his  own  cases  the  feet  presented  at  the 
birth.  Our  case  here  reported  was  a  foot  presentation,  the  labor  was  dif- 
ficult, and  convulsions  with  the  paralysis  immediately  followed  the  de- 
livery. Still  more  conclusive  evidence  of  parturition  with  an  after-coming 
head,  in  the  etiology  of  infantile  hemiplegia,  is  afforded  by  the  two  cases 
reported  by  the  writer  in  the  Am.  Jour.  Obstet.,  Jan.  1885.  Both  were 
breech  presentations.  In  the  first  case  ten  minutes  were  occupied  in 
delivering  the  head,  and  when  born  the  cord  had  ceased  to  pulsate. 
Resuscitation  was  accompanied  by  paralysis  of  the  right  arm,  the  child 
became  gradually  comatose  during  the  six  days  of  its  life,  and  upon 
autopsy  a  large  clot  was  found  covering  the  convexity  of  the  posterior 
half  of  the  left  hemisphere  of  the  cerebrum.    Case  2  lived  twenty-two 

1  Steiner,  Compend.  Children's  Diseases,  1875,  p.  24. 

2  Ross,  Brain,  vol.  v.  No.  3,  p.  344,  1882. 


1885.]        McNutt,  Double  Infantile  Spastic  Hemiplegia. 


75 


days.  During  that  time  it  had  convulsions  with  paralysis  of  the  whole  of 
the  left  side,  including  the  extremities  and  the  face.  The  left  eye  was 
always  open.  Upon  autopsy  the  right  hemisphere  was  found  covered  by 
a  clot  which  dipped  into  the  fissure  of  Rolando,  and  on  account  of  destruc- 
tion of  tissue  was  separated  from  the  lateral  ventricle  here  only  by  the 
ependyma.  The  history  of  these  two  cases  is  similar  to  Elsie's  history, 
to  the  history  of  Ross's  cases,  and  to  the  history  of  Little's  cases.  It  is  a 
legitimate  conclusion  that  had  they  lived,  Case  2  at  least  would  have 
developed  by  cicatrization  the  shrinkage  of  the  central  convolutions,  and 
possibly  the  sinus,  into  the  lateral  ventricle  with  the  convergence  of  the 
neighboring  convolutions,  which  characterize  the  most  marked  cases  of 
this  disease. 

The  intracranial  hemorrhage  of  young  children  is  meningeal  in  type. 
In  the  newly-born1  it  is  said  to  occur  usually  at  the  base  of  the  brain. 
Cruveilhier2  found  the  effusion  about  the  base  of  the  brain  and  the  cere- 
bellum, or  at  the  most,  covering  only  the  posterior  cerebral  lobes.  Cru- 
veilhier's  cases  lived  only  a  number  of  hours.  Paralysis  was  not  present 
in  any  case. 

The  non-recognition,  by  this  great  teacher,  of  meningeal  hemorrhage  in 
other  localities,  is  probably  due  to  the  fact  that  the  subjects  of  hemorrhage 
at  the  base,  as  a  rule,  die,  and  immediate  autopsies  are  obtained,  while 
hemorrhage  at  the  vertex  does  not  so  constantly  destroy  life,  and  hence 
possibly  escapes  analysis.  Little  complains  of  our  slight  information  re- 
garding the  influence  of  the  accidents  of  birth  upon  their  living  subjects, 
among  whom  he  includes  cases  of  club-foot,  wry  neck,  and  many  other 
minor  deformities.  Little  considered  the  deformity  of  Richard  III.  to 
have  belonged  to  the  same  category,  quoting  the  Shakspearian  lines  re- 
garding his  halting  gait,  together  with  the  mention  of  Sir  Thomas  Moore, 
that  the  Duchess  of  Gloucester  had  much  ado  in  her  travail,  he  (Richard 
III.)  being  born  the  feet  forward. 

The  rupture  in  meningeal  hemorrhage  can  seldom  be  located.  In  the 
Case  II.  which  we  have  quoted  from  the  Amer.  Journ.  Ohstet.,  the  effu- 
sion would  appear  to  have  come  from  beneath  the  central  convolutions, 
possibly  from  the  surface  of  the  ependyma.  This  is  shown  by  the  fact 
that  the  brain  tissue  was  here  so  ploughed  up  and  destroyed  as  to  be  re- 
placed by  a  clot,  the  blood  having  evidently  overflowed  the  fissure  of 
Rolando  before  covering  the  hemisphere.  The  pronounced  atrophy  at  the 
base  of  the  convolutions  in  our  own  case  may  indicate  an  eccentric  lesion. 
It  may,  however,  have  been  produced  only  by  the  loss  of  the  blood  supply 
from  ruptured  vessels  on  the  surface  of  the  brain,  for  we  must  take  into 
consideration  the  fact  that  the  base  of  the  convolution  is  developed  later 
than  the  convexity,  which  is  pushed  out  by  the  new  growth,  also  the 

1  Cazeaux,  Treatise  on  Midwifery,  1875,  p.  413. 

2  Cruveilhier,  Anatomie  Path.,  xv.  plate  i. 


7G 


McNutt,  Double  Infantile  Spastic  Hemiplegia.  [Jan. 


physiological  law,  that  the  part  latest  developed  is  the  one  that  is  most 
frequently  malformed.  Upon  this  proposition,  the  relative  immunity  of 
the  convex  portion  of  the  convolution,  only  substantiates  our  theory  of  an 
injury  at  the  time  of  birth,  as  according  to  Flechsig1  the  development  of 
the  convex  portion  would  have  been  completed,  while  the  development  of 
the  accessory  portion  is  not  yet  completed,  and  hence  still  subject  to  in- 
hibition at  that  time. 

The  atrophied  callosum  did  not  suggest  a  secondary  change.  Simple 
arrest  in  that  part  is  not,  however,  opposed  to  the  theory  of  injury  at 
birth,  for  the  reason  that  in  the  ninth  months'  foetus  only  do  its  fibres  com- 
mence to  be  medullated.  From  the  sixth  to  the  fifteenth  week  of  extra- 
uterine life  is  the  more  usual  time  for  their  recognition.2 

The  symmetry  of  the  lesion,  in  a  case  like  our  own,  is  apparently  opposed 
to  the  theory  of  mechanical  or  hemorrhagic  origin.  This  objection  is,  how- 
ever, only  apparent.  Lebert,3  in  139  cases  of  cerebral  hemorrhage,  found 
twenty-one  double,  and  where  double,  similar  points  on  both  sides  were 
affected.  While  Bouchut,4  among  forty  cases  of  meningeal  hemorrhage  in 
adults,  found  in  twenty-three  of  these  cases  both  hemispheres  affected. 
A  symmetrical  meningeal  hemorrhage  in  our  own  case  is,  therefore,  not 
improbable. 

The  dyspnoea  and  the  laryngeal  arrest  is  in  our  case  an  interesting 
feature.  During  life  it  was  supposed  that  the  functions  of  the  pneumo- 
gastic  were  interfered  with.  Dr.  Chapin5  has  reported  a  similar  respira- 
tion in  connection  with  an  inflamed  pneumogastric  nerve  from  the  pressure 
of  a  bronchial  gland.  There  was  no  dysphagia  in  his  case.  In  our  own 
case  the  pneumogastric  nerves  with  their  nuclei  were  intact.  It  is  con- 
ceivable that  the  cerebral  nerves  are  represented  in  the  cortex.  Seguin6 
has  had  laryngeal  paresis  from  hemorrhage  into  the  third  frontal  convolu- 
tion. It  only  remains  to  suggest  that  in  our  case  this  cortical  vagus 
reserve  was  sufficiently  encroached  upon  to  cause  the  symptoms. 

To  recapitulate  :  The  peculiarity  of  the  atrophy  in  Elsie's  case,  namely, 
the  immunity  of  the  convexity  of  the  convolutions  with  the  atrophy  of  the 
callosum  appears  to  locate  the  primitive  lesion  neither  very  much  earlier 
nor  very  much  later  than  the  time  of  birth,  while  the  difficult  labor,  and 
the  convulsions,  with  the  evidence  afforded  by  the  two  cases  which  we 
have  quoted,  locate  it  still  more  closely  in  a  hemorrhage  just  at  that 
period.  We  therefore  consider  parturition  to  have  been  the  cause  for  her 
condition,  and  one  of  the  commonest  agencies  in  the  production  of  her 

1  Flechsig,  Leitungsbahn  in  Gehirn  u.  Ruckenmark,  198. 

2  Flechsig,  1.  c.  p.  34. 

3  Lebert,  Traite  d'Anatomie  Path.,  ii.  p.  60. 
*  Bouchut,  Arch.  Gen.  de  Med.,  v.  261,  1839. 

5  Chapin,  N.  T.  Med.  Jour.,  March  15,  1884. 

6  Seguin,  Opera.  Minor,  i.  205. 


1885.]        McNutt,  Double  Infantile  Spastic  Hemiplegia. 


,77 


disease,  spastic  infantile  hemiplegia.  It  also  seems  probable  that  not  only 
the  paralysis  and  atrophy  of  the  extremities,  but  also  the  dyspnoea,  the 
dysphagia,  and  the  laryngeal  atrophy  must  be  referred  to  the  cortical 
arrest. 

Diagnosis  Infantile  Spinal  Paralysis — Infantile  spastic  hemiplegia 

must  be  differentiated  in  the  first  place  from  infantile  spinal  paralysis. 
The  wasting,  or  non-development  of  the  parts,  might  at  a  cursory  glance 
suggest  this  disease.  Infantile  paralysis,  however,  has  never  been  known 
to  attack  the  whole  body;  one  leg  or  one  arm  will  be  affected.  Some- 
times both  lower  extremities,  but  seldom  both  extremities  of  the  same 
half  of  the  body  are  paralyzed,  never  according  to  Niemeyer,1  and  but 
rarely  according  to  Henoch.2  Infantile  spastic  hemiplegia  presents  con- 
tractures also,  and  frequently  the  implication  of  the  facial  or  other  cere- 
bral nerves.  The  faradic  reaction  is  retained  in  the  paralyzed  muscles, 
the  atrophy  is  slower,  and  the  intelligence  may  be  impaired. 

Double  infantile  hemiplegia  must  be  differentiated  also  from  spastic 
spinal  paralysis,  from  chronic  hydrocephalus,  from  athetosis,  from  dissemi- 
nate sclerosis,  or  steatosis  of  the  brain,  and  possibly  also  from  the  "  con- 
tracture idiopathique"  of  the  French. 

Spastic  Spinal  Paralysis. — Seguin's3  tetanoid  paraplegia  or  the  spastic 
paralysis  of  Erb,4  consists  in  voluntary  inability  to  control  the  part,  with 
exaggerated  reflex  movements  and  contractures.  It  is  bilateral.  It  com- 
mences in  the  lower  extremities  ;  and  was  first  supposed  by  Charcot  to 
be  due  to  a  primary  sclerosis  of  the  lateral  columns  of  the  cord.  An 
autopsy  demonstrating  this  connection  was  made  by  Dreschfeld,5  in  1881. 
Elsie's  condition  simulated  this  state,  in  absence  of  voluntary  inability,  in 
the  exaggerated  reflexes  in  the  muscular  contractures,  and,  beyond  all,  in 
the  fact  that  the  loss  of  motility  and  these  reflexes  were  bilateral  in  their 
distribution.  The  asymmetry  of  her  head,  however,  with  her  inability 
to  talk,  her  dysphagia  and  her  dyspnoea  suggested  a  brain  complication. 

Chronic  Hydrocephalus  There  is  little  in  the  physical  signs  to  dis- 
tinguish a  case  of  chronic  hydrocephalus  from  a  case  of  double  infantile 
hemiplegia,  if  the  skull  be  not  increased  in  size.  The  rolling  down  of  the 
eyeballs  should  be  looked  for,  and  failing  this  sign,  a  diagnosis  would 
depend  upon  the  history  of  the  case. 

Athetosis — Bilateral  athetosis  is  usually  associated  with  idiocy  ;  there 
is  no  true  paralysis,  and  the  peculiar  movements  which  are  more  pro- 
nounced upon  effort,  serve  to  distinguish  it.  Of  one  such  case,  it  is  said, 
that  she  never  was  still,  while  in  double  infantile  hemiplegia  placidity  is 

1  Niemeyer,  Practice  of  Med.,  vol.  ii.  p.  373,  1880. 

2  Henoch,  Diseases  of  Children,  p.  108  (Wood's  Library). 

3  Seguin,  Archives  of  Medicine,  February,  1879. 

*  Erb,  Berliner  klinische  Wochenschrift,  June  28,  1875. 
s  Dreschfeld,  Tr.  Inter.  Med.  Congress,  1881,  vol.  i.  407. 


78 


McNutt,  Double  Infantile  Spastic  Hemiplegia. 


[Jan. 


the  rule.  Athetoid  movements  may,  however,  be  present.  Suckling 
mentions  alternate  flexion  and  extension  of  the  fingers  in  two  of  his  cases. 
The  predominance  of  the  hemiplegic  symptoms  must  then  be  the  diagnos- 
tic point. 

Steatosis. — Concerning  steatosis  or  disseminate  sclerosis,  the  dividing 
line  will  be  still  more  difficult  to  draw.  Simon  has  recently  reported  a 
case  of  the  latter  affection,  under  the  title  of  cerebral  sclerosis  (Rev. 
Mens,  des  Mai.  de  VEnfance,  March,  1884).  This  patient  was  a  girl  of  nine 
years,  completely  paralytic,  and  presenting  contractures  in  the  paralyzed 
members,  the  position  of  which  correspond  with  the  description  given 
for  our  own.  The  child  was  very  restless,  the  paralytic  and  contracted 
limbs  were  continually  in  aimless  motion,  and  she  was  usually  crying  or 
making  inarticulate  sounds.  Her  cutaneous  sensibility  was  normal,  but 
her  intelligence  was  absolutely  lost.  She  had  a  specific  history,  and  at 
the  autopsy  were  found  nodules  of  induration  over  the  anterior  middle 
and  superior  parts  of  the  brain,  particularly  in  the  frontal  and  in  the 
parietal  lobes.  This  degeneration  affected  not  only  the  gray  but  also  the 
white  matter.  The  spots  were  of  the  size  of  a  filbert,  and  were  in  some 
places  of  a  red,  and  in  others  of  a  salmon  color.  The  author  considers  a 
meningitis  to  have  been  primary  in  this  case,  and  the  origin  to  have  been 
syphilitic.  He  says  that  the  restlessness  of  the  child  was  diminished 
under  the  mercurial  and  iodide  of  potash  treatment,  which  was  tried 
shortly  before  death.  Though  called  cerebral  sclerosis,  this  case  appears 
to  be  identical  with  Parrot's1  cases  of  steatosis  of  the  new-born.  These 
nodules  Parrot  supposes  to  be  due  to  malnutrition,  though  frequently 
dependent  upon  a  specific  taint. 

It  appears  to  us  that  the  so-called  idiopathic  contracture  of  the  French 
need  never  be  confounded  with  this  condition,  which  it  resembles  only  in 
the  fact  of  the  contractures  with  the  symmetry  of  their  distribution. 
Idiopathic  contracture  does  not  persist,  there  is  no  atrophy,  and  neither 
fever  nor  convulsions  herald  its  approach. 

In  the  differential  diagnosis  of  double  infantile  hemiplegia  the  history 
of  the  development  of  the  condition  must  have  very  great  weight.  Where 
the  paralysis  supervenes  upon  perfect  health  and  occurs  suddenly  heralded 
by  fever  and  convulsions  the  lesion  of  infantile  spastic  hemiplegia  is  to  be 
suspected.  Where  the  convulsions  immediately  follow  birth,  intra-cranial 
hemorrhage  is  with  a  considerable  degree  o  certainty  its  cause. 

Treatment. — In  considering  the  treatment  of  infantile  spastic  hemiple- 
gia, we  may  remember  that  absolute  paralysis  is  not  present  ;  of  one  it  is 
only  said  that  her  grasp  was  uncertain.  Most  patients  are  able  to  walk 
and  in  a  fashion  to  use  the  paralyzed  part ;  our  own  case,  during  the  last 
months,  commenced  to  grasp  and  became  able  to  hold  up  her  head.    It  is 


i  Parrot,  Arch,  de  Phys.,  p.  59,  1873, 1868,  p.  784. 


1885.] 


Leuf,  Peculiar  Form  of  Pulmonary  Congestion. 


70 


true  that  idiocy  is  frequently  present,  but  it  is  not  necessarily  profound. 
We  would  therefore  recommend  passive  exercise,  gentle  massage,  and  the 
careful  use  of  the  induced  current  with  stimuli  of  an  intellectual  and  moral 
character.  Nourishing  diet  and  fresh  air  are  indispensable.  Iodide  of 
potassium  with  ergot  has  appeared  to  diminish  the  contracture  and  sensi- 
bly to  improve  the  gait  in  one  of  the  cases  which  I  have  now  under  my 
care.  As  prophylaxis  prompt  and  speedy  delivery  of  the  aftercoming 
head  may  be  emphatically  urged. 

One  other  consideration  remains  :  in  the  class  of  cases  proceeding  from 
an  injury  at  birth,  not  having  been  able  to  avoid  the  delay  in  delivery, 
and  having  the  infant  after  birth  in  constantly  repeated  convulsions,  dur- 
ing one,  two,  three,  and  even  nine  days,  can  nothing  be  done  for  its 
relief?  With  diffidence  I  desire  to  suggest  the  opening  of  the  skull  and 
the  removal  of  the  clot.  Surely  the  danger  to  life  and  to  health  in  these 
cases  is  sufficiently  great  to  authorize  such  an  operative  procedure,  if 
there  be  any  possibility  of  success. 

In  concluding,  we  beg  to  present  our  acknowledgments  to  Dr.  Amidon 
and  to  Dr.  Eoberts,  also  to  Dr.  Welch  for  the  kind  assistance  which  has 
made  this  study  possible. 


Article  VI. 

Note  ox  a  Peculiar  Form  of  Pulmoxary  Coxgestiox,  xot  gene- 
rally kxowx  and  Terminating  ix  Suddex  Death:  together  with 
a  Plea  lor  Cardiac  Aspiratiox.  By  A.  H.  P.  Leuf.  M.D.,  Patholo- 
gist to  St.  Mary's  General  Hospital,  Brooklyn,  X.  Y..  and  Secretary  of  the 
Brooklyn  Pathological  Society,  etc.1 

The  two  objects  in  writing  this  note  are  indicated  in  the  title,  i.  e.,  first, 
to  draw  attention  to  a  peculiar  form  of  pulmonary  congestion  that  is  not 
generally  known  nor  properly  understood,  and  which  ends  in  sudden 
death  ;  second,  to  enter  a  plea  in  defence  of  the  operation  of  aspiration  of 
the  right  heart,  as  originally  proposed  by  Dr.  B.  F.  Westbrook,  of  Brook- 
lyn. X.  Y.,  and  performed  by  him  in  one  case. 

Facilities  that  I  may  presume  to  call  unusual  are  afforded  me  every 
year  in  the  study  of  the  pathology  of  several  hundred  cases  of  sudden 
death.  During  the  last  two  years,  I  have  frequently  met  with  cases  of 
the  kind  I  will  describe  more  fully  below.  I  have  recorded,  as  well  as  I 
can  now  remember,  a  little  more  than  one-half  of  those  seen.    My  recorded 

1  Read  before  the  Medical  Society  of  Northampton  Co..  at  Bath,  Northampton  Co., 
Pa..  1884. 


80 


Leuf,  Peculiar  Form  of  Pulmonary  Congestion.  [Jan. 


cases  number  more  than  thirty,  to  which  may  be  added  three  more  made 
within  two  days  of  the  present  writing.  Very  seldom  has  it  happened 
that  I  have  been  called  upon  to  make  an  autopsy  in  these  cases  during  the 
warm  months.  They  occur  most  frequently  in  spring  and  fall,  many  also 
being  encountered  throughout  the  winter.  The  great  majority,  however, 
are  met  with  in  the  course  of  the  temperate  seasons,  when  the  weather 
is  prone  to  change  rapidly  and  in  a  marked  degree. 

In  all  of  these  cases,  both  lungs  were  affected,  and  to  the  same  extent 
with  only  a  few  exceptions.  Whenever  a  difference  between  the  two  sides 
existed,  it  was  only  slight.  With  rare  exceptions,  the  lungs  were  uni- 
formly affected,  there  being  no  patchy  appearance  on  section  and  no  evi- 
dence of  either  ante-mortem  or  post-mortem  gravitation  of  blood.  The 
narrow  apex  or  sharp  anterior  margin  was  as  full  of  blood  as  the  rounded 
posterior  border  or  the  broad  base  resting  upon  the  diaphragm.  In  those 
few  cases  in  which  the  congestion  was  not  uniform,  but  presented  a  patchy 
appearance,  the  lighter  spots  were  no  more  numerous  nor  was  their  loca- 
tion better  marked  in  the  dependent  parts  of  the  lung  than  in  other  por- 
tions. Thus  a  light  congestive  patch  would  be  found  adjoining  a  coal 
black  field  of  lung  tissue  at  the  sharp  free  anterior  margin. 

Similar  conditions  would  be  noticed  throughout  the  same  organ  without 
reference  to  the  laws  of  gravitation.  When  the  congestion  is  uniform,  the 
lung  appears,  on  section,  as  black  as  ink,  and  slight  pressure  causes  an 
exudation  of  thick  and  perfectly  black  blood.  Very  often  there  also  ex- 
ists considerable  oedema,  and  this,  also  frequently,  without  depending  on 
hypostasis,  for  it  may  be  noticed  in  the  uppermost  parts  of  the  organ, 
while  hardly  any  is  seen  in  the  more  dependent  portions.  Crepitation 
is,  .as  a  rule,  present  in  all  parts  of  the  lungs,  and  where  it  is  absent  a 
condition  of  collapse  is  noted.  Occasionally,  of  course,  there  are  found 
solid  tubercular  and  other  deposits  as  in  any  other  lung. 

A  remarkable  peculiarity  in  this  connection  is  the  frequent  absence  in 
the  middle  lobe  of  the  right  lung  of  any  great  degree  of  congestion.  This 
is  most  often  seen  in  cases  of  pneumonitis.  Many  a  case  of  double  pneu- 
monitis, or  others  where  the  upper  and  lower  lobes  of  the  right  lung  were 
involved,  the  left  lung  not  being  affected,  has  shown  the  middle  lobe  to 
be  perfectly  normal. 

The  pleuras  generally  have  a  dark  purplish-red  color,  mottled  here 
and  there  with  irregular  bluish  spots.  It  will  sometimes  happen  that  the 
external  coloration  of  the  lungs  does  not  convey  any  adequate  idea  as  to 
the  intensity  of  the  engorgement  within.  It  is  by  no  means  infrequent 
that  the  necroscopist  is  surprised  beyond  measure  at  the  intensity  of  the 
passive  engorgement  of  the  lung,  after  having  suspected  but  a  slight  con- 
gestion from  the  light  appearance  of  the  outer  surface. 

The  appearance  of  the  heart  and  great  vessels  is  hardly  second  to  the 
condition  of  the  lungs.    I  have  invariably  found  the  right  side  enormously 


1885.]       Letjf,  Peculiar  Form  of  Pulmonary  Congestion. 


81 


distended  and  the  osteum  venosum  entirely  incompetent,  with  its  tricuspid 
valve,  to  stem  the  return  flow  from  the  right  ventricle,  thus  practically 
throwing  the  right  auricle  and  ventricle  into  one  large  auriculo-ventricu- 
lar  cavity.  In  fact,  I  have  this  day  encountered  a  heart  so  dilated,  in  the 
case  of  an  habitual  drunkard,  as  to  admit  of  the  introduction  of  my  whole 
hand,  previously  folded  as  small  as  possible,  beyond  the  metacarpophalan- 
geal articulations.  The  circumference  of  the  right  auriculo-ventricular 
orifice  must,  therefore,  have  been  at  least  18  centimetres,  as  the  smallest 
measurement  around  my  contracted  hand  is  over  20  centimetres.  This  is 
the  largest  osteum  venosum  that  I  have  ever  seen  in  these  cases.  In  most 
of  the  cases  this  opening  easily  admitted  my  four  fingers  and  thumb  as  far 
as  the  middle  of  the  proximal  phalanges,  i.  e.,  was  about  13  centimetres  in 
average  circumference.  The  normal  average  is  10  centimetres,  according 
to  Quain  readily  admitting  three  fingers,  but  as  fingers  differ  in  size,  this 
is  not  a  very  accurate  test.  I  have  also  found  the  pulmonary  artery  dis- 
tended with  dark  blood  in  all  cases.  Its  orifice,  as  a  rule,  permits  of  the 
easy  entrance  of  three  fingers  in  these  instances,  i.  <?.,  is  about  10  centi- 
metres in  circumference.  The  one  in  the  above-mentioned  case  of  the  large 
osteum  venosum  was  fully  13  centimetres  in  circumference.  In  these  cases, 
the  pulmonary  valves  are  always  incompetent,  and  hence  readily  admit 
considerable  regurgitation.  The  left  heart  is  invariably  either  empty  or 
contains  but  a  very  small  quantity  of  blood.  The  pulmonary  veins  are  also 
empty,  or  very  nearly  so.  I  have  always  found  the  whole  heart  relaxed. 
Not  more  than  three  or  four  of  all  the  cases  in  this  class  that  have  come 
under  my  observation  during  the  last  two  years  presented  any  valvular 
disease. 

The  conditions  of  other  organs  varied  greatly.  The  liver  is  usually 
either  healthy,  fatty,  or  in  the  active  or  passive  state  of  chronic  interstitial 
inflammation.  The  spleen  may  be  normal  or  show  an  increase  of  its  con- 
nective tissue.  The  kidneys  are  often  either  in  the  active  or  passive 
state  of  interstitial  inflammation. 

The  principal  feature  in  connection  with  the  abdominal  organs  is  their 
degree  of  sanguination.  In  the  bodies  of  persons  who  are  poorly  nourished 
and  evidently  more  or  less  anaemic,  the  abdominal  organs  are  in  a  condition 
of  marked  exsanguination,  while,  on  the  other  hand,  they  are  gorged  with 
very  dark  blood  in  the  well  nourished  and  plethoric.  Any  variety  of  san- 
guination of  these  organs  is  noticed  between  these  two  extreme  conditions 
of  the  individual.  The  peripheral  veins,  however,  are  in  all  cases  empty 
and  collapsed,  and  in  anaemic  cases,  even  the  vena  porta  and  its  tributa- 
ries are  almost  entirely  devoid  of  blood.  The  capillaries  are  not  as  full  as 
usual  except  in  the  face  and  neck,  where  they  contain  well  carbonized 
blood.  The  cerebral  veins  usually  contain  more  or  less  very  dark  blood 
in  those  who  have  enjoyed  average  health  or  were  plethoric,  but,  other- 
wise, they  are  also  as  devoid  of  their  usual  contents  as  are  the  other  veins. 
No.  CLXXVII — Jan.  1885.  6 


82 


Leuf,  Peculiar  Form  of  Pulmonary  Congestion.  [Jan. 


Etiological  data  are  very  important  factors  in  the  treatment  of  disease, 
and  therefore  the  consideration  of  the  causes  of  these  fatal  congestions, 
though  largely  speculative,  is  fully  within  the  boundaries  of  perfect  pro- 
priety. 

First,  I  have  noticed  that  a  great  proportion  of  these  fatal  congestions 
occur  in  persons  more  or  less  inclined  to  drunkenness,  but  it  is  by  no 
means  limited  to  this  class.  Again  and  again  has  it  occurred  that  some 
of  these  unfortunate  beings  returned  home  intoxicated  and  laid  down  to 
sleep,  never  to  awaken.  Not  only  do  they  die  in  their  beds,  but  upon  the 
floors  of  their  rooms,  in  halls,  streets,  gutters,  in  boxes,  station  and  lodg- 
ing houses,  upon  trucks,  and  in  short,  wherever  a  drunken  person  is  apt  to 
go  for  rest.  Secondly,  that  cold  is  an  important  factor  is  self-evident.  It, 
however,  is  hardly  a  sufficient  cause  for  these  phenomena,  as  it  often  hap- 
pens that  the  person  having  succumbed  to  one  of  these  fatal  congestions, 
of  which  I  speak,  has  been  previously  afflicted  with  an  ordinary  conges- 
tion many  a  time,  and  without  a  bad  result.  Third,  exposure  and  priva- 
tion seem  to  exert  as  potent  an  influence  in  the  production  of  this  malady 
as  does  drunkenness.  Yet,  I  have  often  seen  typical  cases  of  fatal  con- 
gestion in  persons  having  comfortable,  nay,  even  luxurious  homes,  and 
who  were  total  abstainers  from  alcoholic  or  malt  beverages. 

What,  then,  is  the  underlying  cause  of  this  affection,  which  can  ra- 
tionally be  supposed  to  exist  in  all  of  the  cases  that  I  have  seen  ?  To  my 
mind  it  seems  clear  that  the  sine  qua  non  in  its  production  is  essentially  a 
nervous  influence  ;  or,  perhaps,  more  truly  still,  the  absence  of  the  normal 
nervous  control  of  the  pulmonary  circulation.  Whether  this  be  an  affection 
of  the  respiratory  centre,  perhaps  in  a  state  of  constant  irritation,  exerting 
an  inhibitory  influence  over  the  pulmonary  sympathetic,  or  a  depressed 
state  of  that  section  of  the  sympathetic  which  controls  the  pulmonary 
circulation,  or  whether  it  may  be  both,  I  have  not  sufficiently  good  data 
to  enable  me  to  rationally  claim.  It  is,  however,  my  opinion  that  this 
congestion  is  at  first  a  blush  of  the  lungs,  occurring  in  the  same  manner 
as  a  blush  of  the  cheek,  i.  <?.,  by  a  sudden  dilatation  of  the  capillaries,  due 
either  to  an  inhibitory  influence  of  the  cerebro-spinal  axis,  or  a  depression 
of  the  pulmonary  sympathetic.  It  may  be  fair  to  assume,  in  the  uncertain 
state  of  our  knowledge  upon  this  question,  that  both  influences  exist  at 
the  beginning ;  and  that,  while  the  cerebro-spinal  axis  returns  to  its 
normal  state,  the  pulmonary  sympathetic  is  permanently  paralyzed,  and 
thus  the  blood  stagnates  in  the  capillaries  of  the  lungs,  in  consequence  of 
the  inertness  of  its  environing  channels.  That  in  such  a  condition  the 
alternate  contraction  and  dilatation  of  the  left  auricle  and  ventricle,  to- 
gether with  the  aspiratory  function  of  the  thorax,  would  not  be  sufficient 
to  prevent  the  stagnation  of  blood  in  the  lungs,  seems  assured  upon  a 
priori  reasoning,  on  account  of  the  physical  obstacles  (as  friction)  en- 
countered in  the  exceeding  minuteness  and  enormous  multiplicity  of  the 


1885.]       Leuf,  Peculiar  Form  of  Pulmonary  Congestion. 


83 


tubular  network  through  which  the  circulation  takes  place.  This  a  priori 
reasoning  is  proven  to  be  true  on  the  autopsy  table  in  every  one  of  these 
cases.  Almost  all  ,the  blood  is  found  pent  up  in  the  vena  cava,  right 
heart,  pulmonary  artery,  and  lungs.  The  pulmonary  veins,  left  heart, 
arteries,  systemic  capillaries,  and  peripheral  veins,  are  either  entirely  or 
almost  devoid  of  their  usual  contents.  In  very  full-blooded  persons  the 
venous  engorgement  extends  back  into  the  liver,  spleen,  and  kidneys,  and 
sometimes  to  the  brain.  In  no  other  conditions,  that  I  have  ever  seen, 
do  these  three  abdominal  organs  together  appear  so  full  of  black  blood. 
In  no  case,  no  matter  how  full-blooded,  did  the  venous  engorgement  ex- 
tend beyond  the  cavities  of  the  trunk  and  cranium. 

I  will  here  incidentally  mention  that,  as  the  first  stage  of  pneumonitis 
is  different  from  an  ordinary  congestion  of  the  lungs,  and  as  these  fatal 
congestions  of  which  I  write  also  differ  essentially  from  ordinary  pulmo- 
nary hyperamiie,  and  as  these  fatal  congestions  or  engorgements  are  very 
similar  in  appearance  to  the  first  stage  of  pneumonitis,  the  hypothesis  of 
a  nervous  influence  as  a  cause  in  the  one  is  equally  probable  as  the  essen- 
tial factor  in  the  production  of  the  other. 

At  first  there  is  but  slight  disturbance  of  the  equilibrium  between  the 
pulmonary  and  systemic  circulations.  Steadily,  but  surely,  this  dispro- 
portion between  the  two  sides  increases.  The  arterial  side  of  the  circula- 
tion is  losing  its  blood  constantly  in  greater  amount  than  it  is  supplied 
from  the  lung  by  the  pulmonary  veins.  In  time  the  lungs  become  sur- 
charged with  blood.  The  air-chambers  are  diminished  in  size,  on  account 
of  the  tumefaction  of  the  interstitial  structures  of.  the  lung,  by  the  enor- 
mous dilatation  of  the  gorged  capillaries.  Hence  less  air  enters,  and  the 
blood  becomes  extremely  carbonized  and  deoxidized.  All  the  cells  of  the 
body  therefore  suffer  more  or  less  true  asphyxia  ;  nor  is  this  all,  they 
are  robbed  of  a  share  of  their  usual  nourishment.  What  blood  does  pass 
to  the  left  heart,  then,  is  very  poor  in  oxygen.  When  the  lungs  are 
saturated  with  blood  the  right  heart  begins  to  experience  the  pressure  of 
the  blood  that  is  being  pumped  on  by  the  poorly  oxidized  left  ventricle, 
the  arteries,  and  the  capillaries.  Soon  the  pressure  becomes  too  much. 
The  openings  of  the  right  ventricle  begin  to  dilate,  and  their  valves  be- 
come incompetent  to  check  the  return  flow  of  the  current.  The  right  ven- 
tricle forces  some  of  its  contents  into  the  pulmonary  artery  and  lungs,  to 
have  a  share  of  it  regurgitated  a  moment  after.  In  the  same  way  the 
right  auricle  works  with  only  partial  success  ;  for,  in  consequence  of  the 
dilatation  of  the  osteum  venosum,  the  tricuspid  valve  is  ineffectual  in  pre- 
venting the  back-flow  of  blood.  While,  at  first,  the  amount  of  regurgita- 
tion is  small,  it  gradually  increases  so  as  to  amount  to  more  than  that 
which  enters  the  lungs,  and  eventually  hardly  any  passes  to  its  normal 
destination,  and  nearly  all  the  blood  simply  moves  up  and  down  in  a  con- 
tinuous column,  extending  from  the  division  of  the  pulmonary  artery 


84 


Leuf,  Peculiar  Form  of  Pulmonary  Congestion.  [Jan. 


through  the  right  ventricle  and  auricle  into  the  upper  and  lower  venae 
cavce.  That  the  patient  should  be  able  to  survive  long  with  a  heart  in 
this  condition  is  an  impossibility.  His  exhausted  heart  yields  in  despair 
in  a  brief  period  unless  prompt  relief  is  afforded.  Medicinal  remedies  are 
of  exceedingly  doubtful  utility,  for  the  very  means  (the  circulation)  by 
which  we  carry  them  to  the  parts  to  be  affected  are  incompetent.  Me- 
chanical relief,  therefore,  is  most  urgently  called  for,  but  more  of  this 
later  on. 

The  symptomatology  of  this  affection  is  very  meagre,  as  far  as  I  have 
been  able  to  determine  in  a  study  of  the  cases  of  which  I  speak.  The 
duration  is  very  short,  probably  never  exceeding  twenty  to  forty-eight 
hours  from  onset  to  termination  ;  but  I  am  inclined  to  fix  the  usual  time 
at  about  six  or  eight  hours.  It  occurs  much  oftener  in  males  than  in 
females,  and  I  have  never  observed  it  in  children.1  There  is  frequently  a 
sense  of  impending  danger.  In  one  of  these  cases  that  I  have  recorded  I 
could  get  no  further  history  than  that  the  patient  was  a  little  quiet,  and 
said  to  his  wife,  "  I'm  afraid  I'm  going  to  die,  Annie."  This  impending 
sense  is  absent,  however,  in  many  cases,  as  far  as  could  be  ascertained. 
There  may  or  may  not  be  either  unilateral  or  bilateral  pain.  An  almost 
invariable  symptom,  if  any  at  all  are  noted,  is  oppressed  respiration. 
Thus  one  of  my  earliest  cases  was  that  of  a  young  butcher,  of  average 
height  and  splendid  muscular  development.  It  had  been  a  comparatively 
mild  day  in  autumn  and  he  had  carelessly  exposed  himself  to  the  sudden 
fall  of  temperature  occurring  during  the  latter  part  of  the  afternoon. 
When  he  arrived  home  in  the  evening,  about  9  o'clock,  he  first  began  to 
feel  uncomfortable.  He  said  that  he  felt  chilled  to  (he  bone,  and  could 
not  get  warm  ;  that  breathing  was  rather  difficult  and  unsatisfactory  ;  and 
repeatedly,  in  the  midst  of  joyful  surroundings,  expressed  the  conviction 
that  he  might  never  leave  his  bed  alive  after  having  entered  it  that  night. 
A  strong  mustard  plaster  was  applied  to  his  chest  by  one  of  his  relatives, 
and  his  feet  were  bathed  in  hot  mustard-water.  Then  he  went  to  bed.  In 
the  morning  his  body  was  lifeless  and  cold,  the  latter  fact  proving  that  he 
must  have  been  dead  for  some  hours.  He  went  to  bed  after  IIP.  M.,  and 
his  room  was  entered  before  5  o'clock  the  next  morning.  Thus  he  must 
have  died  within  two,  or  at  most  three,  hours  after  retiring.  The  autopsy 
was  made  about  fourteen  hours  after  death.  He  had  the  blackest  lungs 
I  have  ever  seen,  for  they  looked  like  tar.  His  left  heart  and  arteries,  as 
well  as  the  pulmonary  veins,  were  empty,  while  the  right  heart  was  enor- 
mously distended  with  black  blood,  as  were  also  the  pulmonary  artery  and 
the  vence  cavce.  His  liver,  spleen,  and  kidneys  were  in  a  state  of  the  most** 
intense  venous  congestion.    The  vena  porta  contained  a  little  blood.  The 

1  The  case  of  a  child  I  saw  a  short  time  ago  seems  to  have  been  one  of  this  class.  It 
was  but  a  few  weeks  of  age,  and  had  been  poorly  fed  and  exposed  to  the  weather. 


1885.]        Leuf,  Peculiar  Form  of  Pulmonary  Congestion. 


85 


cerebral  veins  were  almost  empty.  All  the  peripheral  veins  were  collapsed 
and  bloodless.  And  this  state  of  affairs  prevailed  in  a  very  full-blooded 
young  man.  The  spinal  cord  was  examined,  but  presented  nothing  ab- 
normal. 

A  feeling  of  weariness  is  also  occasionally  complained  of. 

While  dying,  the  face  and  neck  very  slowly  become  livid,  but  not  as 
much  so  as  in  death  from  asphyxia.  Death,  when  it  has  been  observed 
by  intelligent  lay  persons,  was  said  to  have  occurred  without  a  struggle, 
and  in  a  moment. 

In  one  case,  a  tall,  stout,  and  full-blooded  young  man,  twenty-eight 
years  of  age,  was  chatting  with  his  family.  Talking  became  more  and 
more  difficult,  until  it  was  considered  advisable  to  send  for  a  physician, 
but  this  was  postponed.  The  symptoms  increased  in  severity  till  con- 
tinuous talking  became  very  difficult,  when  he  suddenly  reeled  off  his 
chair  with  a  look  of  fear  and  perplexity,  and  was  dead.  His  brain  was 
examined  and  found  normal,  and  the  only  signs  to  account  for  the  sudden 
loss  of  life  were  discovered  in  the  heart  and  lungs,  which  presented  the 
appearances  described  in  the  preceding  cases. 

The  symptoms,  then,  are  briefly  all  those  of  a  severe  cold,  minus  the  cough, 
although  that  is  also  present  at  times.  The  most  marked  symptoms,  very 
often,  are  the  oppression  of  breathing  and  the  sense  of  impending  death. 
Upon  the  dead  body,  percussion  discovers  marked  dulness  over  all  parts 
of  the  chest,  and  as  all  parts  of  the  lung  crepitate  in  most  of  these  cases,  a 
diminished  respiratory  sound,  associated  with  moist  rales,  would  most 
likely  be  announced  by  ante-mortem  auscultation. 

The  treatment  of  this  affection  should  be  prompt,  decisive,  and  radical. 
It  is  not  fair  to  the  patient  to  attempt  the  use  of  doubtful  means.  If  any 
measure  is  already  at  hand  which  promises  relief  as  soon  as  applied,  that 
is  the  one  to  be  used.  Should  no  such  remedy  exist,  it  is  perfectly  just 
to  devise  some  radical  plan,  which,  if  pursued,  will  most  likely  eventuate 
in  the  recovery  of  the  threatened  sufferer.  Just  the  means  that  are  here 
indicated  have  been  devised  and  practised  by  my  friend,  Dr.  Benjamin 
F.  Westbrook,  of  Brooklyn,  N.  Y.,  i.  e.,  the  operation  of  cardicentesis,  or 
aspiration  of  the  heart.1  Even  this  remedial  measure,  prompt  as  it  acts, 
must  be  quickly  applied.  No  time  is  to  be  lost,  as  every  minute  may 
count. 

I  have  detailed  one  case  in  which  strong  counter-irritation  had  been 
applied  to  the  thoracic  walls  and  the  feet  without  avail.  This  is  by  no  means 
the  only  one  on  my  list.  Others  have  been  similarly  treated,  previous  to 
death,  with  the  like  result.  The  immediate  danger  is  not  from  asphyxia, 
but  from  heart  failure,  due  to  over-distension  of  the  right  side,  and  gross 

1  See  paper  by  Dr.  Benjamin  F.  Westbrook,  entitled  "  On  Abstraction  of  Blood  from 
the  Right  Heart,  as  a  means  of  relieving  intense  Pulmonary  Congestions,"  in  the 
Medical  Record  of  December  23,  1882. 


8G 


Leuf,  Peculiar  Form  of  Pulmonary  Congestion.  [Jan. 


incompetence  of  the  valves  guarding  the  two  orifices  of  the  right  ventricle. 
Belief,  and  the  promptest  kind  too,  must  be  tendered  this  organ,  in  pref- 
erence to  any  other.  Thus,  there  can  be  no  doubt  of  the  utility  of  the 
abstraction  of  enough  blood  from  the  right  heart  to  allow  it  to  regain  its 
normal  functional  activity. 

As  is  the  fate  of  all  innovations,  however,  whether  good  or  bad,  so  it 
was  that  of  Dr.  Westbrook's  operation  to  meet  with  opposition,  and  that 
of  a  decided  character.  It  is  also  damaging  to  the  interests  of  our  pro- 
fession that  original  thought  should  be  opposed  by  iconoclastic  criticism, 
as  too  frequently  happens,  and  has  occurred  in  connection  with  the  opera- 
tion of  cardicentesis.  Let  me  beg  of  all  critics  to  maintain  that  imper- 
turbability of  true  impartial  scientific  criticism,  and  I  will  aver  that  their 
opinions  will  receive  more  respectful  attention  from  those  for  whom  they 
are  meant  than  would  result  from  any  other  course. 

With  reference  to  a  rather  harsh  editorial  appearing  in  the  Medical 
News  of  February  3,  1883,  I  will  say  but  a  few  words :  First,  to  the 
question  as  to  what  it  matters  if  the  great  venous  trunks  are  perforated, 
there  are  two  answers  :  one,  that  it  matters  not;  the  other,  even  if  it  did, 
they  could  never  be  perforated  except  by  a  careless  or  bungling  operator. 
There  is  much  less  chance  of  touching  the  venous  trunks  in  this  operation 
than  there  is  of  cutting  the  brachial  artery  or  median  or  musculo-cutaneous 
nerves  in  phlebotomy  anterior  to  the  elbow-joint.  Second,  it  is  not  true 
that  "when  a  needle  is  inserted  the  movements  of  the  heart  must  widen 
the  orifice  made."  A  priori  reasoning  would,  in  the  first  place,  refute 
this  on  account  of  the  elasticity  of  the  auricular  walls  and  their  fluid  con- 
tents. This  is  proved  de  facto ,  as  no  mark  could  be  found  upon  any  part 
of  the  auricle  operated  upon  by  Dr.  Westbrook  to  indicate  the  point  of 
entrance  of  the  needle. 

Two  writers  in  the  Medical  Record  of  January  20,  1883,  Dr.  Hal.  C. 
Wyman,  of  Detroit,  Mich.,  and  Dr.  Wra.  T.  Cheesman,  of  Auburn, 
N.  Y.,  file  their  opinion  against  the  operation  of  cardicentesis.  The 
former,  however,  tends  to  become  sarcastic  and  jocose  toward  the  end  of 
his  letter.  It  is  hard  to  conceive  how  the  cardiac  valve  might  ever  be 
"  stitched  up,"  but  that  divulsion  of  the  cardiac  prifices  is  much  more 
plausible  can  readily  be  seen.  I  have  long  ago  deemed  divulsion  of  these 
openings  a  practicable  operative  procedure,  and  should  not  hesitate  to  have 
it  done  upon  myself  in  case  of  stenosis  of  one  of  my  own  cardiac  orifices. 
Lack  of  thorough  anatomical  knowledge  makes  even  bold  surgeons  timid 
at  times,  and  this  is  a  fact  that  was  fully  appreciated  by  Prof.  Billroth, 
when  he  exhorted  his  students  to  thoroughly  master  anatomy.1 

Dr.  Cheesman  asks  if  it  is  not  an  unhappy  result  to  have  even  the 

1  "  Anatomy,  gentlemen  !  Anatomy,  and  again  Anatomy  !  A  human  life  often 
hangs  on  the  certainty  of  your  knowledge  in  this  branch." 


1885.]        Letjf,  Peculiar  Form  of  Pulmonary  Congestion.  87 


slightest  hremo-pericardium  follow  the  operation  of  aspirating  the  right 
auricle?  I  say  no.  If  it  is  not  success  to  save  human  life,  although  at 
the  expense  of  even  considerable  outpouring  of  blood  into  the  pericardium, 
rather  than  keep  the  pericardium  clear  at  the  expense  of  the  patient's  life, 
then  no  operation  is  successful.  We  cut  off  both  lower  extremities  to  save 
life,  and  if  this  object  is  attained,  we  speak  of  it  as  a  successful  operation. 
If  we  save  life  by  cardiac  aspiration,  though  at  the  expense  of  effusing  an 
ounce  of  blood  into  the  pericardium,  it  is  a  complete  success,  for  the  blood 
is  easily  absorbed,  while  we  promptly  deliver  a  human  being  from  immi- 
nent death,  and  leave  him  as  well  as  he  was  before  his  trouble  set  in. 
How  different  is  this  from  keeping  him  here  minus  two  lower  limbs.  And 
yet  the  former  should  be  a  failure  and  the  latter  a  success  !  He  further 
says  :  "  Bearing  in  mind  the  tenuity  of  the  auricular  wall,  and  the  danger 
that  it  shall  tear  itself  by  motion  against  the  needle  (not  a  fanciful  danger 
by  any  means),  can  we  consider  its  puncture  any  other  than  a  most 
hazardous  expedient  ?"  It  is  true  that  the  auricular  wall  is  tenuous,  but 
it  must  also  be  borne  in  mind  that  it  is  elastic  and  contractile.  No  better 
practical  demonstration  could  be  asked  for  by  the  most  exacting  than 
resulted  in  the  post-mortem  examination  of  Dr.  TVestbrook's  case.  As 
was  said  once  before,  it  was  impossible  to  find  any  sign  upon  the  wall  of 
the  auricle  that  might  indicate  the  place  of  entrance  of  his  needle.  The 
doctor  also  states  that  he  has  known  cardicentesis  to  have  been  resorted 
to  in  cases  of  immediate  danger  from  heart  failure,  but  he  does  not  tell  us 
how  often,  by  whom,  where,  or  when,  nor  with  what  success.  Will  he 
please  publish  an  account  of  the  cases  he  knows  of,  for  they  might  prove 
valuable  ?    His  questions  will  be  answered  later  on. 

Dr.  C.  L.  Dana  reports  two  cases  of  cardicentesis  in  the  Medical  Record 
of  February  3,  1883.  In  both,  aspiration  was  practised  after  somatic 
death,  but  probably  previous  to  complete  cellular  death.  Half  an  ounce 
of  blood  was  withdrawn  from  the  first  case  without  any  effect.  That  is  a 
result  that  I  should  have  anticipated,  and  would  doubt  the  success  of  the 
operation  of  restoring  life  if  even  several  ounces  had  been  abstracted, 
unless  death  had  resulted  primarily  from  heart  failure,  and  even  then 
other  means  would  have  to  be  resorted  to  for  the  purpose  of  starting  the 
circulation.  The  operation  was  designed  for  the  relief  of  the  heart  labor- 
ing under  physical  difficulties,  and  especially  without  organic  lesions,  and 
not  to  awaken  its  vitality  once  it  had  ceased  to  beat.  In  one  case  the 
puncture  made  by  the  needle  in  entering  the  heart  was  distinctly  seen  at 
the  autopsy.  It  is  proper  to  bear  in  mind,  though,  that  the  operation  was 
performed  upon  the  dead  body.  The  first  case  cannot  count  on  either 
side  of  this  question,  but  is  valuable  in  showing  that  the  advantages  of 
this  operation  had  been  previously  appreciated  to  a  certain  extent.  In 
the  second  case,  the  heart  continued  in  action  some  time  after  respiration 
had  stopped.    He  does  not  say  whether  he  abstracted  blood  from  the 


88 


Leuf,  Peculiar  Form  of  Pulmonary  Congestion. 


[Jan. 


right  ventricle  while  the  heart  was  in  action  or  after.  So  this  case,  too, 
as  it  now  stands,  is  of  no  value  in  settling  the  doubt  in  the  minds  of 
those  wrho  would  like  to  see  more  proof  either  way.1 

The  value  of  cardicentesis  over  venesection  consists  in  its  being  simpler 
and  requiring  paraphernalia  less  disheartening  to  the  patient,  being  more 
prompt  in  its  effect,  necessitating  less  loss  of  blood,  and  that  its  perform- 
ance is  always  possible,  while  in  some  cases  the  abstraction  of  sufficient 
blood  by  phlebotomy  k  not  only  impossible,  but  sure  to  hasten  death. 
Simplicity  is  always  desirable,  and  what  can  be  a  more  simple  operative 
procedure  than  the  thrusting  of  a  needle  into  the  chest,  especially  as  it 
causes  no  more  inconvenience  than  the  much-used,  valuable  hypodermic 
syringe  ? 

Promptness  is  a  great  desideratum  in  all  operations,  whether  the  pa- 
tient is  under  the  influence  of  an  anaesthetic  or  not,  and  this  is  particu- 
larly the  case  in  instances  in  which  the  heart  threatens  to  give  out  at  any 
moment  on  account  of  physical  impediments.  If  to  this  item  of  prompt- 
ness the  fact  can  be  annexed  that  in  this  operation  the  same  effect  can  be 
produced  by  the  loss  of  less  blood  than  is  the  case  in  phlebotomy  under 
similar  circumstances,  another  point  in  its  favor  is  gained,  and  such  is 
actually  the  fact. 

There  is  one  more  point  in  favor  of  cardicentesis,  and  it  is  a  weighty 
one.  It  is  the  fact  that  this  operation  is  always  possible  and  effectual, 
while  phlebotomy  is  not,  Dr.  C.  L.  Dana  to  the  contrary  notwithstanding, 
for  he  says :  "In  cases  of  laboring  heart  I  should  vastly  prefer  venesec- 
tion, whose  potency  is  unquestionable." 

It  is  certainly  true,  as  has  been  remarked  to  me,  that  if  one  end  of  a 
tube  is' placed  in  a  volume  of  water,  while  suction  is  made  at  the  other 
extremity  with  the  mouth,  water  will  flow  through  the  tube  till  suction  is 
arrested.  Furthermore,  it  will  keep  on  flowing  if  the  end  of  the  tube  to 
whiich  suction  has  been  applied  be  placed  lower  than  the  level  of  the  vol- 
ume of  water  from  which  that  is  derived  which  passes  through  the  tube. 
This  is  on  the  principle  of  the  siphon.    Both  may  be  combined  with  in- 

1  On  page  820  of  the  March  number  of  the  Edinburgh  Medical  journal  for  this  year, 
is  a  brief  account,  by  a  gentleman  signing  himself  "  An  Asylum  Assistant,"  of  a  case 
of  probable  transfixion  of  the  lower  part  of  the  heart  with  a  three  and  a  half  inch 
needle,  or  shawl-pin,  for  suicidal  purposes.  The  symptoms  were  apparently  alarm- 
ing, but  subsided  upon  the  withdrawal  of  the  offending  body  to  reappear  for  a  short 
time  in  several  hours  ;  after  this  complete  recovery  followed.  The  reporter  of  this 
case  considered  the  patient  to  have  had  a  narrow  escape,  and  no  doubt  she  had,  but  it 
is  inexplicable  to  me  how  he  justified  his  opinion  in  viewing  this  case  as  proving  the 
operation  of  "  cardicentesis  out  of  the  range  of  practical  surgery,"  for  the  very  fact  of 
her  rapid  and  complete  recovery  following  almost  immediately  upon  the  extraction  of 
the  needle  goes  to  show  that  whatever  danger  there  may  be  (and  I  doubt  that  there  is 
any  at  all),  is  obviated  by  the  removal  of  the  cause  which  excites  it.  I  cannot  help 
viewing  this  gentleman's  case  as  one  to  prove  cardicentesis  practicable,  and  it  seems 
to  me  that  so  will  he  upon  further  deliberation. 


1885.]       Letjf,  Peculiar  Form  of  Pulmonary  Congestion. 


89 


creased  effect.  This  proposition  has  been  presented  in  favor  of  phlebo- 
tomy as  against  cardicentesis.  But  the  pulmonary  circulation  is  not 
conducted  on  the  principle  of  the  siphon,  so  this  must  be  eliminated.  The 
blood  is  propelled  from  the  right  heart  through  the  lungs  to  the  left  heart 
by  several  forces.  The  vis  a  tergo  of  the  columns  of  blood  in  the  syste- 
mic venous  trunks  pushed  along  by  the  systemic  capillaries  ;  the  alternate 
contractions  and  relaxations  of  the  veins  from  compressions  due  to  flexions 
and  extensions  caused  by  muscular  action  ;  the  effect  of  muscular  con- 
tractions on  the  blood  within  the  muscles  and  between  them  ;  and  the 
contractions  of  the  veins  themselves,  though  slight ;  all  these  tend  to 
push  the  blood  forward  to  the  right  heart.  The  other  forces,  consisting 
in  the  comparatively  passive  dilatation  of  the  left  heart  in  response  to  the 
blood  pressure  from  behind,  which  is  caused  by  the  compression  of  the 
lungs  and  their  contained  bloodvessels  in  expiration  ;  and  the  capillary 
attraction  and  contraction  itself  are  the  ones  that  send  the  current  to  the 
left  heart. 

The  dilatation  of  the  left  heart  is  not  a  vis  a  f route,  as  is  so  often  stated. 
Were  radiating  fibres  attached  to  the  ventricular  walls  so  as  to  draw  them 
out,  arid  tend  thus  to  create  a  vacuum  in  the  general  left  auriculo-ventri- 
cular  cavity,  it  would  necessarily  be  an  active  force,  drawing  the  blood 
into  these  cavities  as  a  so-called  suction-pump  "  draws  "  water.  This, 
however,  is  not  so,  for  the  left  heart  dilates  only  passively  in  obedience 
to  the  inpouring  of  blood  from  the  lungs. 

The  aspiratory  function  of  the  thorax  also  does  not  act  as  a  propelling 
force  to  the  arterial  side  of  the  lesser  circulation.  Whatever  blood  it 
does  "  suck"  into  the  thoracic  cavity  is  by  way  of  the  ascending  and  de- 
scending vence  cavce.  It  tends  to  draw  both  air  and  blood  into  the  lungs, 
but  only  succeeds  in  attracting  that  blood  which  comes  from  the  peripheral 
venous  system  to  the  right  heart  and  lungs^  while  on  the  other  hand,  it 
retards  the  circulation  through  the  pulmonary  veins  from  the  lungs,  for  to 
these  latter  organs  all  the  blood  now  tends  that  can  go  that  way.1  There 
is  no  impediment  in  its  course  on  the  venous  side  from  the  furthermost 
systemic  capillaries,  while  on  the  arterial  side  there  is  a  very  effectual 
barrier  to  any  back  flow  not  far  from  the  lungs,  consisting  in  the  bicuspid 
valve.  The  aspiratory  function  of  the  thorax  can,  therefore,  have  no  ef- 
fect in  filling  the  left  heart,  because  the  bicuspid  valve  effectually  prevents 
aspiratory  attraction  of  the  arterial  column  beyond  it  by  inspiration. 

1  The  aspiratory  effect  of  inspiration  upon  the  heart  has  been  fully  considered,  but 
not  incorporated  in  the  body  of  the  paper,  because  the  aspiratory  effect  upon  the  lungs 
preponderates  over  that  exercised  upon  the  left  ventricle,  which  is  opposed  to  them. 
In  inspiration,  the  lungs  tend  to  attract  blood  from  the  pulmonary  veins  and  left 
auricle,  while  the  left  auricle  and  ventricle  oppose  it.  The  effect  is  a  flowing  of  the 
current  in  this  direction  during  inspiration.  This  mechanism  seems  so  simple  that  I 
think  it  unnecessary  to  enter  into  further  details,  as  it  must  be  evident  to  all  upon 
slight  consideration. 


90 


Leuf,  Peculiar  Form  of  Pulmonary  Congestion.  [Jan. 


Daring  inspiration  the  blood  tends  to  the  lungs,  as  well  as  the  air,  from 
all  possible  directions.  Its  effect  is  most  positively  felt  by  that  column  of 
blood  naturally  coursing  towards  these  organs,  i.  e.,  the  pulmono-systemic 
venous  column.  The  valves  in  the  veins,  the  tricuspid,  and  the  pulmo- 
nary open  toward  the  heart  and  lungs,  and  therefore  offer  no  obstruction 
to  the  increased  flow  in  this  direction.  The  opposite  prevails,  though,  in 
the  other  (arterial)  column.  Here  the  attraction  is  contrary  to  the  cur- 
rent, which  tends  from  the  lungs.  The  bicuspid  and  aortic  valves  open 
from  the  lungs  and  close  to  prevent  regurgitation  to  the  organs  whence 
the  current  came.  Thus,  during  inspiration,  the  venous  flow  is  accele- 
rated and  the  arterial  retarded.  In  expiration  it  is  contrariwise.  Here 
the  lungs  and  thoracic  parietes  contract,  causing  a  tendency  to  expel  air 
and  blood  in  all  possible  directions.  The  blood  current  now  is  from  the 
lungs.  It  is  contrary  to  the  venous  column  and  against  the  pulmo- 
nary and  tricuspid  valves  and  the  valves  of  the  veins,  which  prevent  re- 
gurgitation during  the  diastole  and  period  of  cardiac  rest  when  expiration 
is  in  progress.  The  direction  of  the  current,  though,  is  now  with  the 
arterial  column,  and  its  flow  is  accelerated  through  the  pulmonary  veins 
and  left  heart,  the  bicuspid  and  aortic  valves  now  offering  no  resistance. 

As  is  well  known,  the  heart  beats  about  four  times  during  one  respira- 
tory act.  Inspiration  is  active  and  a  little  longer  than  expiration,  which 
is  passive.  The  former  aids  the  venous  column  which  passes  through  the 
vessels  that  are  larger,  thinner,  weaker,  and  less  elastic  than  the 
arteries,  and  through  the  weaker  side  of  the  heart  ;  the  latter  assists  in 
propelling  the  blood  along  the  left  heart  and  arteries,  which  are  in  them- 
selves much  better  adapted  to  carry  on  the  circulation  than  the  veins  and 
right  heart.  The  lungs,  therefore,  give  more  aid  to  the  venous  and  weaker 
circulation  than  they  do  to  the  stronger  arterial.  The  pulmonary  circula- 
tion then  may  be  viewed  as  follows  :  The  right  heart  pumps  blood  into 
the  pulmonary  artery  and  its  branches  until  they  are  well  distended  ;  in- 
spiration takes  place  and  draws  the  blood  from  the  pulmonary  artery  into 
the  pulmonary  capillaries  and  at  the  same  time  attracts  the  blood  from  the 
large  venous  trunks  into  and  close  up  to  the  right  heart ;  expiration  then 
forces  the  blood  from  the  capillaries  through  the  pulmonary  veins  into  the 
left  heart.  These  three  steps  might  be  designated  in  their  order  as  first, 
that  of  venous  distension  ;  second,  that  of  capillary  distension  ;  third,  that 
of  arterial  distension.  The  circulation  thus  passes  through  the  lungs  in  a 
series  of  three  stages  during  every  respiration.1 

Thus  there  is  normally  every  provision  for  a  perfect  and  ever  moving 
circulation  through  the  respiratory  organs.    No  better  arrangement  could 

1  It  is  a  well-established  fact,  to  my  mind,  that  the  perfection  of  the  pulmonary 
circulation  depends  upon  the  character  of  the  respiration.  I  have  many  a  time  veri- 
fied by  post-mortem  examination  the  fact  that  the  lungs  are  in  a  state  of  passive  con- 
gestion just  in  proportion  to  their  defective  ante-mortem  respiratory  activity. 


1885.]        Leuf,  Peculiar  Form  of  Pulmonary  Congestion. 


91 


have  been  invented  by  a  skilled  engineer  to  prevent  any  improper  working 
of  this  mechanism.  The  nervous  systems  control  the  contractile  power  of 
the  pulmonary  vessels  and  thus  exert  the  same  influence  upon  the  circu- 
lating fluid  passing  through  the  lungs  that  the  brakeman  on  a  railway  car 
exercises  on  the  speed  of  the  train  by  the  judicious  manipulation  of  his 
brake.  Should,  now,  this  lesser  or  pulmonary  circulation  become  de- 
ranged at  any  time,  it  is  very  evident  that  one  or  more  of  the  forces  con- 
trolling it  must  have  been  primarily  at  fault.  It  must,  therefore,  exist 
either  in  the  right  heart,  the  lungs,  or  the  left  heart.  In  all  these  cases 
that  I  have  considered,  and  for  the  alleviation  of  which  Dr.  B.  F.  West- 
brook  devised  his  operation,  the  fault  did  not  lie  in  the  right  heart  pri- 
marily, nor  did  it  exist  in  the  left  heart;  necessarily  then,  this  first  fault 
existed  in  the  lungs.  To  determine  what  the  exact  cause  was  here,  is 
rather  difficult,  but  let  us  see. 

Respiration  is  not  modified  in  these  cases  except  very  late  in  the  disease 
and  then  only  as  a  consequence  of  the  deranged  state  of  the  pulmonary 
circulation.  The  contractility  of  the  capillaries  and  smaller  vessels  in  the 
lungs  is  the  only  factor  in  the  maintenance  of  the  pulmonary  circulation 
left  us  that  may  be  at  fault.  This  we  cannot  exclude,  and  it  is  the  only 
one  that  it  is  impossible  to  cast  aside.  That  those  little  vessels  should 
have  taken  it  upon  themselves  to  suddenly  and  in  concert  refuse  to  con- 
tract as  was  their  usual  habit,  is  not  a  rational  inference.  Some  higher 
power  must  have  directed  them,  and  this  power  is  beyond  a  doubt  located 
in  either  the  medulla,  or  the  pulmonary  sympathetic,  or  both.  The  brake- 
man  is  at  fault.  The  fact,  however,  remains  the  same,  i.  e.,  that  the 
original  trouble  was  pulmonary  and  very  likely  began  in  the  nervous  sys- 
tem, and  if  the  arterial  side  of  the  circulation  was  not  able  to  prevent  this 
difficulty,  it  certainly  is  powerless  to  check  it  afterward.  This  becomes 
still  more  evident  when  it  is  recollected  that  the  arterial  side  of  the  circu- 
lation is  gradually  diminishing  in  vigor  by  slowly,  but  steadily  and  surely, 
losing  its  blood,  and  that  blood  is  over-crowding  the  intra-thoracic  venous 
system.  Eventually  the  peripheral  veins  become  empty  and  nearly  all  the 
blood  has  retreated  to  the  lungs,  the  right  heart,  and  its  two  great 
feeders. 

While  it  is  universally  conceded  that  the  abstraction  of  blood  is  in  these 
cases  the  best  remedy,  the  general  impression  is  that  simple  venesection 
"  at  the  elbow  is  efficient  and  safe,  while  cardicentesis  is  dangerous  and 
inadmissible.  Let  it  be  remembered,  though,  that  the  peripheral  veins 
are  almost  entirely  devoid  of  blood.  The  only  direction  from  which  blood 
can  be  drawn  is  from  the  arterial  side  through  the  capillaries,  for  the 
veins  have  valves,  and  being  almost  entirely  empty  no  blood  can  be 
obtained  from  the  right  heart  and  lungs  except  in  the  most  roundabout 
manner,  i.  e.,  through  the  systemic  venules,  capillaries,  arterioles,  and 
arteries,  the  left  heart  and  pulmonary  veins,  capillaries  and  artery. 


92 


Leuf,  Peculiar  Form  of  Pulmonary  Congestion. 


[Jan. 


Should  arteriotomy  be  attempted  as  a  more  direct  means  of  getting  the 
blood  from  that  side  of  the  circulation,  as  it  must  come  from  there  any- 
way if  cardicentesis  is  not  performed,  the  end  of  the  patient  would  only 
be  hastened  by  depletion  of  the  arteries  in  a  shorter  time  than  nature  is 
doing  it  herself.  For  as  the  heart  has  not  aspiratory  power,  the  loss  will 
not  be  made  up  by  sufficient  outpouring  of  blood  from  the  lungs  through 
the  pulmonary  veins  in  response  to  the  sudden  depletion  of  the  vessels. 
By  going  to  the  auricle,  though,  we  get  ahead  of  the  valves  in  the  veins, 
go  at  once  to  the  seat  of  the  trouble,  abstract  blood  directly  from  the 
parts  overloaded  with  it,  and  give  immediate  relief  without  depleting  the 
arteries. 

Dr.  John  B.  Roberts1  cites  two  cases  of  accidental  heart  puncture 
resulting  beneficially  to  the  patients.  In  one,  that  of  Roger,  "  200  grins, 
of  pure  venous  blood"  were  withdrawn  from  the  heart.  He  further  says  : 
"  Death  occurred  five  months  later  from  long  existing  dilatation  and 
valvular  disease  of  the  heart."  In  the  other,  Hulke's  case,  4  grms.  of 
venous  blood  were  also  withdrawn,  and  "  she  died  four  weeks  later  from 
a  complication  of  diseases,  and  the  autopsy  revealed  cardiac  dilatation 
and  valvular  changes."  He  further  adds  in  reference  to  this  case  by 
quoting  from  a  previous  paper  of  his,  as  follows :  "The  abstraction  of 
the  blood  seemed  to  relieve  the  distended  heart  much  better  than  phlebo- 
tomy would  have  done,  as  was  evinced  by  the  diminution  of  threatening 
symptoms  and  the  decrease  of  the  area  of  dulness,"  Additional  refer- 
ences are  given  in  support  of  the  claim  of  the  absolute  harmlessness  of 
cardicentesis. 

In  referring  to  Dr.  B.  F.  Westbrook's  point  of  selection  for  the  intro- 
duction of  the  needle,2  Dr.  Roberts  is  inclined  to  prefer  entering  the 
right  ventricle  "  through  the  fourth  interspace,  about  one  and  a  half  or 
two  inches  to  the  left  of  the  median  line  of  the  sternum."  He,  however, 
yields  the  point  of  deference  in  Dr.  Westbrook's  favor. 

In  listening  to  Dr.  Roberts  when  he  read  his  paper  on  "  The  Surgery 
of  the  Pericardium"  before  the  Anatomical  and  Surgical  Society  of 
Brooklyn,  N.  Y.,  in  1881,  I  heartily  endorsed  all  he  said,  and  at  that 
time  was  convinced  that  divulsion  of  the  cardiac  orifices  in  case  of  stenosis 
would  be  a  safe  and  practicable  operation. 

I  have  previously  said  that  Dr.  Westbrook's  single  operation  of  car- 
dicentesis was  successful.  I  reiterate  that  statement.  Here  is  what 
he  says  in  his  report  of  the  case  :  "  As  I  was  anxious,  however,  to 
avoid  any  possible  risk  of  increasing  the  peril  of  any  patient,  I  chose  for 
the  subject  of  the  operation,  which  I  am  about  to  describe,  a  case  in 

1  See  a  paper  by  Dr.  John  B.  Roberts  on  "Heart-puncture  and  Heart  Suture  as 
Therapeutic  Procedures,"  read  before  the  College  of  Physicians  of  Philadelphia, 
January  3,  1883,  and  appearing  in  the  Medical  News  of  January  13,  1883. 

2  In  the  right  third  intercostal  space  close  to  the  sternal  border. 


1885.]        LeuFj  Peculiar  Form  of  Pulmonary  Congestion. 


93 


which  all  chance  of  recovery  had  disappeared."1  The  first  attempt  was 
a  failure,  inasmuch  as  the  needle  penetrated  the  aorta,  and  the  operation 
was  abandoned,  although  the  needle  had  been  taken  from  the  aorta  and 
placed  in  the  auricle.  Later  on  it  was  tried  again  as  a  last  resort,  and 
about  100  grms.  of  fluid  blood  were  withdrawn.  The  patient  was  more 
comfortable  as  a  result,  and  expressed  himself  as  feeling  much  better. 
The  doctor  had  only  hoped  for  palliation  in  this  case,  he  obtained  it,  thus 
far  he  was  successful.  If  a  man  accomplishes  what  he  desires  to  do,  he 
is  undoubtedly  successful.  I,  too,  believe  with  him  that  had  the  opera- 
tion been  performed  sooner,  and  had  there  been  much  more  blood  ab- 
stracted (probably  300  grms.),  complete  recovery  might  have  followed. 

In  the  proceedings  of  the  Brooklyn  Pathological  Society2  will  be 
noticed  a  case  reported  by  Dr.  B.  F.  TTestbrook,  in  which  he  says  his 
operation  would  have  done  undoubted  good  had  it  been  performed. 
Replying  to  several  inquiries  he  further  expresses  himself  on  this  subject. 
I  quote  the  whole  paragraph  : — 

'•In  reply  to  questions  from  Dr.  Wimderlich.  Dr.  Wallace,  and  others.  Dr. 
W.  stated  that  bleeding  from  the  peripheral  veins  was  not  at  all  equivalent  to 
direct  abstraction  of  blood  from  the  right  heart.  On  such  desperate  cases  as 
those  for  the  relief  of  which  he  advised  this  procedure,  the  blood  is  found  accu- 
mulated in  the  great  veins  of  the  trunk  and  head.  The  arteries  were  poorly 
filled,  and  the  peripheral  veins  almost  empty.  Though  blood  could,  of  course, 
be  abstracted  from  them,  it  would  not  run  backward  from  the  great  veins  them- 
selves, owing  to  the  valves,  but  would  have  to  come  around  through  the  poorly- 
filled  arterial  system,  and  thefiow  would  be  so  slow  that  collateral  channels  would 
serve  to  undo  most  of  the  good  that  was  being  done  ;  and  before  any  appreciable 
effect  could  be  exerted  upon  the  right  heart,  all  the  blood  that  would  How  would 
have  been  abstracted.  AVhat  was  necessary  in  such  a  desperate  case  was  to 
rapidly  diminish  the  flow  of  blood  into  the  right  ventricle,  in  order  to  allow  it  to 
empty  itself  and  regain  its  equilibrium.  He  thought  the  danger  in  puncturing 
the  heart  was  greatly  overestimated.  The  heart  is,  in  reality,  the  toughest, 
most  long-enduring  organ  in  the  body,  and,  unless  it  were  clumsily  done,  such  an 
operation  as  he  advised  would  do  no  harm.  He  also  wished  to  call  attention  to 
the  fact  that  he  only  advised  it  in  desperate  cases,  where  there  was  no  hope  of 
relief  from  other  less  radical  measures." 

I  wish  to  take  exception  to  but  one  thing  in  the  above  quotation,  and 
that  is  the  last  expression.  There  is  no  reason  to  my  mind  why  this  ope- 
ration should  be  a  "  dernier  ressort"  to  be  used  in  extremis.  I  wish  to 
recommend,  as  I  understand  Dr.  Eoberts  intends,  that  if  this  operation  is 
to  be  done  at  all.  it  should  be  done  as  early  as  possible.  We  have  every 
inferential  reason  to  believe  that  it  is  harmless,  and  whatever  practical 
knowledge  there  is  on  the  subject  only  tends  to  justify  the  inference  that 
it  is  devoid  of  danger. 

The  lack  of  a  thorough  knowledge  and  of  a  perfect  acquaintance  with 
physiological  and  pathological  rules  and  processes  makes  the  majority  of 

1  Italics  my  own. 

2  Published  in  the  "  Proceedings  of  the  Medical  Society  of  the  County  of  Kings"  for 
Oct.  1883. 


94 


Ddhbing,  Dermatitis  Herpetiformis. 


[Jan. 


the  members  of  our  profession  timid.  It  is  altogether  inexplicable  to  me, 
after  a  careful  study  of  this  subject,  how  it  can  be  that  this  simple  opera- 
tive procedure  has  been  so  strongly  objected  to,  unless  the  objections  are 
based  entirely  on  erroneous  conclusions  resulting  from  a  defective  con- 
sideration of  this  question.  My  closing  sentiment  is  to  let  the  anatomist, 
pathologist,  and  surgeon  persevere  and  conquer,  that  he  may  prove  to 
his  stationary  brethren  that  the  end  of  possibilities  is  as  yet  afar  off ! 


Article  "VII. 

Case  of  Dermatitis  Herpetiformis  caused  by  Nervous  Shock.  By 
Louis  A.  Duhrlng,  M.D.,  Professor  of  Skin  Diseases  in  the  University  of 
Pennsylvania. 

In  November,  1878,  I  was  asked  by  my  friend,  the  late  Dr.  F.  F. 
Maury,  to  see  a  "  curious  case  of  bullous  skin  disease"  under  his  care. 
It  proved  to  be  a  marked  example  of  what  I  have  described  as  dermatitis 
herpetiformis.1  The  following  notes,  which  I  think  worthy  of  record, 
were  made  at  the  time.  The  disease  was  then  fully  expressed,  and  showed 
the  lesions  not  only  in  abundance  but  in  all  stages  of  development. 

The  patient  (Capt.  K — )  is  a  man  thirty-four  years  of  age,  of  large 
frame,  stout  and  strong,  and  in  the  enjoyment  of  good  general  health.  He 
never  experienced  any  disease  of  the  skin  until  six  weeks  ago,  when  the 
present  eruption  made  its  appearance.  There  is  no  family  history  worthy 
of  record. 

While  gunning  in  the  meadows,  he  unexpectedly  found  himself  in  a 
bog  of  soft,  blackish,  strong-smelling  earth,  into  which  he  sank  deeper 
with  every  step.  He  at  once  recognized  the  nature  of  the  spot  and  the 
danger,  and  endeavored  to  extricate  himself,  but  this  proved  no  easy 
matter,  for  with  every  step  he  sank  deeper  into  the  mire,  until  in  a  short 
time  he  was  buried  up  to  his  armpits.  He  realized  his  extreme  danger, 
and  looked  forward  to  a  speedy  and  miserable  death.  After  struggling 
for  a  full  half  hour  in  the  above  predicament  he  succeeded  in  seizing  a 
tuft  of  grass  just  within  reach.  By  gradually  working  himself  loose  and 
pulling  on  the  grass  he  finally,  in  an  exhausted  state,  managed  to  reach 
firm  ground.  He  was  carried  home  in  a  weak  condition,  bathed  and 
cared  for.  Three  days  after  this  adventure,  which  had  greatly  shocked 
his  whole  system,  the  eruption  appeared  in  the  form  of  small,  variously 
shaped,  round,  oval  and  angular  vesicles,  or  small  "  blisters  containing 
clear  fluid." 

They  came  out  in  number,  and  were  scattered  over  the  flexor  surfaces 
of  arms  and  forearms.  When  first  noticed  they  were  pin-head  in  size, 
and  were  not  accompanied  by  areolae,  but  seemed  to  rise  directly  from 

1  Communication  read  before  the  Section  on  Medicine  of  the  American  Medical 
Association,  May  6,  1884.  Journal  of  the  Am.  Med.  Assoc.,  Aug.  30,  1884.  See,  also, 
Amer.  Journ.  of  Med.  Sci.,  Oct.  1884. 


1885.] 


Duhring,  Dermatitis  Herpetiformis. 


95 


the  sound  skin  ;  two  days  later,  however,  inflammation  surrounded  their 
bases.  At  first  they  were  free  of  itching,  but  towards  the  fourth  or  fifth 
day,  by  which  time  they  had  slowly  grown  to  the  size  of  peas,  this  symp- 
tom set  in  violently.  On  the  second  day  of  the  attack  scattered  lesions 
of  the  same  character  appeared  here  and  there  over  the  trunk,  legs,  and 
thighs,  and  were  especially  numerous  on  the  posterior  surfaces  of  the 
thighs,  over  the  shins,  and  about  the  ankles,  and  were  quite  symmetrically 
distributed.  On  the  trunk  they  were  on  the  back,  chiefly  between  the 
scapula,  and  on  the  abdomen  about  the  umbilicus  and  pubes.  On  the  chest 
they  were  few  in  number  and  disseminated. 

By  the  fifth  or  six  day  they  had  attained  the  size  of  large  peas — in 
short  became  blebs  ;  were  tensely  distended  with  clear,  serous  contents ; 
showed  no  disposition  to  rupture ;  and  were  accompanied  with  slight 
areolae.  The  itching  now  became  annoying  and  was  constant,  the  desire 
to  scratch  being  uncontrollable.  The  general  health  remained  good  ;  no 
chilliness  or  fever.  About  this  date  he  was  rubbed  with  olive  oil,  which 
aggravated  his  condition,  the  skin  by  the  next  day  becoming  hot  and 
more  irritable.  New  lesions  continued  to  appear,  especially  on  the  back, 
and  the  older  ones  increased  in  size  without  showing  any  sign  of  rupturing, 
and  where  two  or  more  were  in  close  proximity  they  often  coalesced. 

From  the  sixth  to  the  thirteenth  day  he  had  no  rest,  the  itching  being 
of  the  most  harassing  character.  About  the  eleventh  day  the  lesions 
became  darker,  the  contents  showing  a  distinct  orange-yellow  color,  and 
instead  of  being  serous  in  character  were  thicker  and  of  a  "jelly-like" 
consistence,  so  that  when  the  blebs  opened  with  a  knife  the  mass  could  be 
removed  as  a  semi-solid  gelatinous  substance.  On  the  fourteenth  day  the 
skin  generally  and  the  lesions  assumed  a  dark-reddish,  bluish-red  color, 
while  the  latter  contracted  and  in  a  few  days  became  crusted  and  hard, 
so  that  with  his  finger  he  could  "  knock  them  off,"  a  dark-reddish  stain 
remaining.  The  eruption  at  this  date  was  at  its  height.  The  blebs  were 
very  numerous,  the  whole  surface  being  literally  covered.  The  scalp,  face, 
ears,  penis  and  scrotum,  and  even  the  verge  of  the  anus,  were  attacked,  the 
palms  and  soles  being  the  only  regions  that  escaped.  The  mouth  was  like- 
wise unaffected.  The  lesions  varied  in  size  from  a  pea  to  a  walnut,  the 
average  size  being  that  of  a  silver  dime  ;  the  larger  ones  were  generally 
formed  by  the  coalition  of  two  or  more  lesions.  They  were  semi-globular 
in  shape,  tensely  distended,  and  in  no  instance  flattened  or  umbilicated. 
None  burst  spontaneously,  but  many  were  ruptured  by  violence  ;  they 
invariably  burst  with  "  a  crack"  or  "  explosion."  As  already  stated,  crust- 
ing took  place  in  the  course  of  a  few  days,  the  crust  being  of  a  yellowish- 
brown  or  dark-brown  color,  and  not  bulky.  After  these  became  detached, 
he  observed  about  the  bases  of  the  original  lesions  a  few  small  pin-head 
sized  "  whitish  points"  or  pustules,  which  multiplied  and  grew  rapidly, 
itched,  and  burned ;  were  raised ;  ran  together  in  many  instances  ;  and  in 
four  or  five  days  developed  into  large  yellowish  pustules,  some  of  them 
being  as  large  as  cherries.  Nearly  all  of  these  lesions,  hundreds  in 
number,  were  punctured,  the  walls  collapsing  and  the  contents  flowing 
freely  but  being  somewhat  turbid.  This  outbreak  constitutes  what  he 
terms  the  second  attack.  The  lesions  were  as  abundant  as  in  the  first 
attack,  and  while  showing  a  disposition  to  appear  on  the  sites  of  the  old 
lesions  yet  came  out  also  on  sound  skin.  Poultices  were  applied,  and 
later  crusts  formed  as  before,  which  in  the  course  of  a  few  days  became 
detached,  leaving  dark-reddish  spots  and  stains. 


96 


Duheing,  Dermatitis  Herpetiformis. 


[Jan. 


He  now  rapidly  recovered  and  remained  nearly  well  for  a  week,  when 
the  third  attack  set  in.  This  was  ushered  in  by  malaise,  chills,  heat, 
nervousness,  and  a  general  itching  of  the  surface,  the  eruption  developing 
much  more  rapidly  than  before.  The  lesions  were  for  the  most  part 
distinctly  pustular  in  character,  the  others  being  vesico-pustular,  vesi- 
cular and  bullous  ;  were  flat,  surrounded  with  inflammatory  areolae,  and 
itchy.  They  appeared  only  on  the  extremities  and  over  the  abdomen. 
They,  differed  in  their  distribution  from  the  former  lesions  in  being 
grouped,  two,  three  or  more  manifesting  themselves  in  close  proximity, 
often  coalescing. 

Present  Condition. — November  22,  1878.  He  is  now  suffering  with 
the  remains  of  the  third  attack,  just  described,  to  which  within  the  week 
has  been  added  a  fourth  outbreak.  New  lesions  have  been  coming  out 
from  day  to  day.  He  is  confined  to  bed,  and  is  suffering  with  a  profuse 
multiform  eruption  occupying  the  greater  portion  of  the  general  surface.  It 
consists  of  vesicles,  blebs,  vesico -pustules,  and  pustules  of  various  sizes  and 
shapes,  and  in  all  stages  of  evolution  ;  erythematous  (light  and  dark  red) 
patches  and  stains,  for  the  most  part  the  remains  of  former  lesions  ;  exco- 
riations and  scratch-marks,  and  crusts,  though  these  latter  lesions  are  by  no 
means  abundant.  The  multiformity  of  the  lesions  is  striking.  Vesicles, 
blebs,  and  pustules  are  in  about  equal  proportion,  and  are  so  intermingled  as 
to  exist  side  by  side.  The  vesicles  and  blebs  maybe  first  considered,  and 
I  speak  of  them  together  for  it  is  impossible  to  draw  a  line  of  distinction 
between  them  ;  the  difference  is  merely  of  size.  They  exist  in  large 
numbers,  in  hundreds.  They  vary  in  size  from  a  pin-head  to  a  walnut 
and  larger,  the  majority  averaging  between  a  split  pea  and  a  hazel-nut. 
They  are  semi-globular  or  flat  in  form,  and  are  either  tensely  distended  or 
flaccid,  the  former  condition  existing  in  all  of  the  smaller  lesions.  They 
rise  abruptly  from  the  surrounding  skin  to  the  height  of  from  one  to 
several  lines,  have  moderately  thick  walls,  similar  to  the  lesions  of  pem- 
phigus, and  show  no  disposition  to  rupture  spontaneously.  There  is  no 
sign  of  umbilication.  They  are  of  all  shapes,  the  majority  being  circular 
or  ovalish  ;  but  some  are  irregular  in  outline  and  show  angular, 
"  puckered"  borders,  as  is  often  seen  in  herpes  zoster,  in  which  event  they 
are  usually  surrounded  with  bright-red,  highly  inflammatory  areolae. 
Many  of  the  vesicles  and  blebs  rise  up  without  areolae,  looking  like  mag- 
nified sudamina.  They  have  a  pearly  or  pale-yellowish  color,  and,  as  in 
the  case  of  other  similar  lesions,  refract  light,  which  gives  them  a 
glistening  appearance.  The  contents  are  for  the  most  part  clear,  but 
some  are  cloudy  and  in  many  instances  are  more  or  less  tinged  with  blood, 
producing  a  mottled  or  streaked  bluish-red  hemorrhagic  look. 

The  pustules  are  likewise  in  all  stages  of  evolution  both  as  to  size  and 
extent  of  pustulation.  Some  are  distinct  pustules  no  larger  than  pin- 
heads,  flat  or  semi-globular  in  form,  and  circular  or  irregular  in  outline  ; 
while  others  of  the  same  size  and  larger  have  evidently  been  vesicles  and 
blebs,  and  are  passing  into  pustules.  Still  others  are  the  size  of  peas  and 
cherries  and  are  distinctly  pustular,  like  the  lesions  of  true  simple 
impetigo,  and  contain  whitish  pale-yellowish  puriform  contents.  Some 
are  in  a  perfect  state  of  preservation,  semi-globular  or  accuminate  in  form  ; 
others  are  more  or  less  collapsed.  As  stated,  inflammatory  areolae  surround 
almost  all  of  the  larger  pustules. 

As  regards  distribution,  no  region  is  free  except  the  palms  of  the  hands. 
It  is  a  very  general  eruption,  the  lower  extremities  exhibiting  the  most 


1885.] 


D uhring ,  Dermatitis  Herpetiformis. 


97 


lesions.  The  flexor  surfaces  are  especially  invaded.  Upon  the  thighs 
and  legs  there  is  not  a  square  inch  that  is  not  the  seat  of  disease.  The 
skin  which  is  not  occupied  by  distinct  lesions  is  dark  red  and  violaceous  in 
color.  The  ankles  are  literally  encircled  with  blebs  and  pustules,  many 
of  which  have  run  together  forming  large,  elongate,  flaccid,  partly  bloody, 
dependent  blebs.  There  is  everywhere  a  tendency  for  the  lesions  to 
group,  and  while  owing  to  their  great  multitude  this  is  not  striking  in  all 
regions,  it  is  nevertheless  very  manifest  in  certain  localities,  as  on  the 
buttocks  and  thighs.  The  groups  are  for  the  most  part  small,  consisting 
of  from  three  to  live  lesions  situated  within  a  radius  of  an  inch.  In  other 
places  a  dozen  or  more  lesions  occupy  an  area  the  size  of  the  palm  of  the 
hand. 

A  peculiarity  of  the  lesions  is  their  disposition  to  coalesce.  Inclining 
to  manifest  themselves  in  ill-defined  clusters  of  two,  three  or  more,  as 
they  increase  in  size  they  run  together,  forming  larger  lesions.  Around 
the  immediate  circumference  of  these  lesions,  whether  vesicular  or  pustu- 
lar, smaller,  flat  pustules  or  vesicles,  the  size  of  pin-heads,  are  in  many 
instances  present.  When  ruptured  the  lesions  crust  over  with  flat,  light, 
yellowish  crusts.  Removing  these,  superficially  excoriated,  moist,  reddish 
surfaces,  having  sharply  defined  irregular  vesicular  or  pustular  borders  are 
exposed  to  view.  Everywhere  about  the  older  lesions  there  is  noted  a 
disposition  on  the  part  of  the  process  to  extend  itself  in  a  creeping  manner 
while  healing  in  the  centre.    Itching  is  present,  and  is  very  distressing. 

Dec.  19.  A  month  has  elapsed  since  the  last  note.  During  this  period  four 
distinct  attacks  or  crops  of  eruption  have  manifested  themselves.  The 
lesions  in  the  first  three  attacks  were  of  the  same  character  as  those  in 
the  outbreak  of  November  22d,  just  described  at  length,  namely,  vesicles, 
blebs  and  pustules,  with  but  little  inclination  to  intermediate  forms,  while 
in  the  present  eruption  vesico-pustules  predominate.  The  last  two  attacks 
have  been  milder,  with  smaller  lesions,  but  accompanied  with  more  itching. 
The  general  course  of  the  disease,  the  disposition  of  the  lesions  to  clus- 
ter, and  the  regions  invaded,  have  been  the  same  as  on  previous  occasions. 
At  present  the  eruption  is  characterized  by  many  small,  and  some  large, 
variously  shaped,  vesicles,  vesico-pustules  and  pustules,  occurring  in  patches 
or  scattered  over  the  surface,  in  all  stages  of  evolution,  together  with 
numerous  excoriations,  ruptured  or  torn  lesions,  crusts  and  scales  seated 
upon  a  dark-red,  violaceous,  mottled,  pigmented  skin,  the  remains  of  former 
attacks.  The  patient  is  able  to  be  about  the  house  ;  his  general  health  is 
good.  He  has  used  lately  alkaline  tarry  lotions.  Arsenious  acid,  in  doses 
of  one-fortieth  of  a  grain,  has  also  been  taken  for  the  last  three  weeks ; 
also  quinia,  and  a  general  tonic  treatment. 

In  December,  1882  (four  years  after  the  last  note),  I  received  a  note 
from  the  patient,  stating  "  I  am  still  troubled  with  the  disease,  and  it  has 
not  failed  to  put  in  an  appearance  at  certain  periods  since  you  saw  me  in 
1878,  although  the  blisters  and  pustules  have  gradually  become  less,  both 
in  number  and  in  size.  At  certain  times  since,  within  the  year,  I  was  so 
free  of  eruption  that  at  one  time  I  thought  surely  I  was  rid  of  my  pest. 
I  can  always  tell  two  or  three  days  before  the  eruption  will  appear  by  the 
coming  on  of  an  itching  sensation.  During  the  past  six  months  I  have 
had  two  attacks." 

The  history  of  this  case,  including  the  cause  of  the  disease — a  violent 
shock  to  the  nervous  system,  is  both  interesting  and  instructive.  The 
No.  CLXXVII  Jan.  1885.  7 


98  Oliver,  A  Correlation  Theory  of  Color-perception.  [Jan* 


bullous  variety  predominated,  and  when  I  first  saw  him,  it  was  highly 
developed ;  subsequently,  however  (as  in  almost  every  case  that  I  have 
encountered),  other  lesions,  especially  pustules,  manifested  themselves. 
The  constitutional  symptoms  accompanying  one  exacerbation  were 
marked. 


Article  VIII. 

A  Correlation  Theory  of  Color-perception.1  By  Charles  A.  Oliver, 
A.M.,  M.D.,  one  of  the  Ophthalmic  and  Aural  Surgeons  to  St.  Mary's  Hos- 
pital, Philadelphia. 

For  some  time  past  the  author's  attention  has  been  directed  towards 
the  many  conflicting  and  opposing  theories  of  color-perception,  some  so 
filled  with  falsities  and  absurdities  as  to  render  them  ridiculous,  and  others 
so  veiled  with  useless  perplexities  as  to  maim  and  alter  their  intended 
significance.  Whilst  he  is  fully  cognizant  of  the  fact  that  he  is  but  add- 
ing to  the  already  overfilled  list,  he  does  not  hope  for  indulgence  if  he  be 
in  error,  nor  does  he  apologize  for  anything  that  he  may  say.  Individual 
firm  convictions  are  presented  in  the  knowledge  that  the  only  way  for 
theory  to  become  a  law,  is,  that  each  shall  contribute  his  mite  of  truth 
even  though  it  be  buried  in  a  mass  of  rubbish.  Taking  for  granted  that 
the  Huygenian  or  undulatory  hypothesis  of  the  imponderables  is  accepted, 
and  that  a  difference  in  the  number  of  vibrations  makes  a  change  in  natural 
result,  it  must  be  self-evident  that  there  can  be  given  three  positive  asser- 
tions. First.  That,  as  these  actions  are  perceived,  there  must  be  organs 
able  to  appreciate  them.  Second.  That  each  series  of  organs  must  have 
an  apparatus  able  to  respond  to  the  quality  of  its  perceived  impression. 
Third.  That  as  all  natural  imponderable  stimuli  are  the  resultants  of  a 
mere  difference  in  the  number  of  vibrations  of  one  and  the  same  ether,  the 
organs  for  the  receipt  of  the  different  varieties  must  be  but  analogues  and 
modifications  of  each  other. 

Starting  with  the  idea  that  each  sensory  organ  is  so  adapted  as  to  be 
able  to  receive  its  variety  of  impression,  the  assertion  that  there  is  a  cor- 
relation in  structure  and  action  is  arrived  at.2  This  cannot  be  denied. 
Take  the  lowest  sensation  of  animation,  touch,  and  endeavor  to  compare 
it  with  the  highest,  sight.  The  tactile  sense  is  seen  in  simplest  proto- 
plasmic mass,  and  it  alone  enables  this  primary  form  of  living  mechanism 
to  exist.    There  has  been  given  a  quality  to  receive  one  of  the  simplest 

1  This  theory  was  brought  forward  in  a  preliminary  note  published  in  the  Phila- 
delphia Medical  Times  for  June  28,  1884.  The  present  writing  is  the  discussion  of  the 
subject  in  extenso. 

2  It  is  not  necessary  to  discuss  the  first  two  assertions. 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  99 


impressions  of  natural  force,  an  actual  contact  with  a  resultant  action. 
What  is  the  visual  sense  in  man,  the  highest  creation,  but  a  complex  mass 
of  simple  elements,  an  engine  capable  of  receiving  many  more  impressions 
from  the  imponderables.  What  is  vision  but  the  result  of  an  exalted 
character  of  contact1  upon  a  physical  difference  so  arranged  as  to  be 
adjusted  to  the  receipt  of  undulations  equivalent  to  those  of  light !  The 
physical  tactile  apparatus  does  not  differ  in  any  way  from  the  physical 
color  apparatus  except  in  its  form  ;  the  latter  a  more  highly  constructed 
variety  of  the  former,  each  being  adapted  for  its  kind  of  stimulus.  Of 
course  every  grade  of  animal  life  has  its  percentage  of  sensory  power 
dependent  upon  the  special  development  of  the  individual.  The  rate  of 
increase  being  not  only  in  the  number  of  senses,  but  also  in  the  evolution 
of  an  individual  form.  This  is  well  exemplified  by  the  sharp  sight  of 
some  birds,  the  quickness  of  hearing,  and  the  keeness  of  smell  of  some 
animals. 

There  cannot  be  any  doubt  of  the  fact  that  the  special  sensory  portion 
of  the  organ  of  sight  is  intended  wholly  and  solely  for  the  determination 
of  color.  The  thought  that  the  sense  of  light  constitutes  the  only  visual 
factor  of  many  of  the  lower  grades  of  animal  life,  and  that  it  must  have 
been  the  primary  form  in  the  evolution  of  the  now  existent  human  visual 
sense,  is,  strictly  speaking,  incorrect.  Natural  colors  are  the  exponents 
of  a  series  of  undulations  of  waves  of  light  existing  between  two  deter- 
minate  ratios.  Colorless  light  is  the  complete  synthesis  of  such  color 
vibrations.  The  more  numerous  the  color  combinations,  the  purer  the 
light ;  the  purer  the  light,  the  less  colored  it  is ;  the  less  colored,  the  less 
visible.  Pure  light  is  invisible.  Light  to  be  seen  must  be  colored,  it 
must  be  impure.  Consequently  visual  perception  is  of  color  and  not  of 
light,  of  which  color  there  may  be  thousands  of  intensities  of  a  single 
character  of  vibration  from  a  dull  reflection  of  a  given  natural  red  to  the 
most  intense  reflection  of  the  same  natural  red.  All  visual  apparatuses, 
from  the  very  simplest  to  the  most  complex,  receive  impressions  of  vary- 
ing intensities  of  color.  The  simplest  form  of  visual  apparatus  has  pro- 
bably but  a  few  differentiations  of  impure  light  under  its  command. 
Thus  in  the  epidermal  eye  spots  of  the  most  rudimentary  types  of  animal 
existence,  where  resident  nerve  energies  have  been  lifted  from  the  sensa- 
tion of  varieties  of  heat  vibrations  into  varieties  of  light  vibrations,  the 
impressions  are  limited  to  a  few  of  the  varying  intensities  of  impure, 
colored  solar  beams.  As  the  scale  of  life  force  is  ascended,  the  numbers 
of  received  impressions  increase,  dependent  not  only  upon  acquired  powers 
during  the  life  of  the  animal,  but  upon  the  direct  result  of  hereditary 
transmission  of  more  highly  developed  physical  structures  capable  of  finer 
and  more  complex  action.    This  continues  in  an  interchangeable  and 


1  The  so-called  "  indirect." 


100         Oliver,  A  Correlation  Theory  of  Color-perception.  [Jan. 

irregular  ascent  until  the  acme  is  probably  reached  in  some  of  the  car- 
nivorous types  of  tropical  birds. 

When  the  human  visual  apparatus  is  first  placed  in  the  worlds  and  is 
exposed  to  color  waves,  it  has  nerve  structures  and  material,  which 
although  never  having  seen  the  component  colors  of  impure  light,  are 
physically  fitted  to  respond  to  many  of  its  vibrations,  just  as  the  leg, 
though  never  having  acted,  has  its  definite  parts,  such  as  the  supporting 
bones,  the  propelling  muscles,  the  governing  nerves,  and  the  supplying 
vessels,  each  in  readiness  for  immediate  action.  The  first  moment  that  a 
beam  of  colored  light  is  focused  upon  a  sentient  point  of  an  infant's  organ 
of  sight,  there  is  a  transformation  of  the  impinged  natural  stimulus  into 
an  equivalent  nerve-energy  which  is  transmitted  to  a  cell,  or  plants  a  new 
cell  in  that  infant's  cerebral  cortex,  thus  giving  the  receiving,  transmit- 
ting, and  recording  cells  each  a  new  quality.  A  second  impression  is 
similarly  received,  a  third,  and  a  fourth,  each  stamping  the  working 
machinery  with  its  representative  mark.  Repetition  upon  repetition  of 
this  occurs  in  all  of  the  available  responsive  nerve  materials,  each  single 
cell  adding  its  mite,  each  mite  strengthening  and  giving  greater  power  to 
the  organism,  and  each  organism  capable  of  perceiving  as  many  colors  as 
it  holds  under  its  jurisdiction.  Assuming  that  complete  external  synthesis 
of  natural  color  results  in  colorless  light,  and  that  incomplete  combination 
in  impure  or  colored  light  (the  impure  light  being  divided  into  invisible 
and  visible),  it  must  be  concluded  that  the  value  of  the  total  nerve  force 
belonging  to  the  various  parts  of  one  sensory  filament  is  equal  to  a  quo- 
tient represented  by  the  sum  total  of  all  of  its  individual  sensations  if 
they  had  been  extraneously  combined  to  form  some  multiple  color.  From 
the  theorems  of  natural  color  which  follow,  it  will  be  seen  that  this  quo- 
tient of  value  must  be  equal  to  some  impure  or  pure  white,  but  whilst  this 
is  undoubtedly  so,  yet  in  order  to  avoid  confusion,  the  value  of  each  fila- 
ment's resident  power  and  related  perceptive  nerve-force  will  be  ordinarily 
designated  as  its  normal  power — merely  using  the  specific  terms  when 
necessary.  In  these  statements  form,  magnitude,  distance,  etc.,  are  totally 
disregarded,  because  they  are  the  results  of  combined  action,  muscular 
changes  in  and  on  the  eye,  changes  in  intensity  of  natural  vibration,  other 
sensory  impressions  both  previously  and  simultaneously  associated,  memory  j 
intelligence,  etc.  These  taken  in  measure,  or  in  all,  in  conjunction  with 
the  knowledge  acquired  by  the  sensory  portion  of  the  organ  of  sight,  con- 
stitute what  is  called  sight,  the  acme  of  visual  result.  To  briefly  illustrate, 
take  the  illusory  effect  of  a  picture  representing  an  every-day  scene.  Here 
by  the  careful  disposition  of  color  and  color  only,  the  artist  is  enabled  to 
seemingly  designate  form,  magnitude,  distance,  etc.,  in  fact  all  of  the 
factors  of  sight.  In  this  instance  it  must  be  acknowledged  that  the 
sensory  portion  of  the  organ  of  sight  is  excited  by  color  vibrations  alone, 
yet  it  is  said  that  by  this  excitement  the  mind  is  brought  to  believe  that 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  101 


actual  form,  actual  magnitude,  and  distance  are  in  existence.  How  much 
more  so  for  photographs  where  there  are  nothing  but  the  so-called  black- 
white  intensities  to  act  as  stimuli  !  A  moment's  reflection  will  show  how 
faulty  the  assertion.  The  mind  through  the  aid  of  the  senses  associates 
previous  knowledge  with  the  present  color  perception,  which  gives  rise  to 
a  pseudo-reality,  and  the  picture  appears  real.  Place  the  organ  of  sight 
in  an  unaccustomed  situation  where  previous  knowledge  cannot  be  of  any 
value.  Allow  it  to  gaze  on  a  picture  representing  the  same  subject  as 
before,  though  now  seen  vertically  over  the  side  of  a  balloon,  and  it  will 
be  found  to  be  at  an  utter  loss  to  correctly  recognize  anything  but  color ; 
no  definite  ideas  of  form,  magnitude,  distance,  etc.,  can  be  given.  There 
is  no  previous  knowledge,  and  sight  is  imperfect.  How  difficult  are  the 
attempts  to  estimate  the  length  of  time  occupied  during  the  falling  of  a  small 
slip  of  white  paper  from  a  high  tower  to  an  uniform  green  sward  !  How 
often  the  calculation  that  the  object  has  reached  the  ground  is  incorrect ! 
The  organ  of  sight  is  placed  in  a  new  and  a  novel  situation,  where  it  has 
no  previous  knowledge  to  associate  with  its  present  color  perception,  and 
as  a  consequence,  sight  is  imperfect  and  the  calculation  false.  Let  it 
assume  the  same  position,  say  several  hundred  times,  and  there  will  be 
found  to  be  the  most  accurate  idea  of  both  the  time  of  falling  and  the 
correct  distance  for  that  place.  There  is  now  previous  knowledge  to  asso- 
ciate with  the  color  perception,  and  sight  for  that  situation  becomes  more 
nearly  perfect.  Crude  and  vague  ideas  of  magnitude  and  distance  are 
always  given  by  the  inexperienced  to  lone  vessels  on  open  seas  or  solitary 
mountains  in  deserts.  In  each  case  the  eye  sees  as  much  and  as  well  as 
it  ever  did,  yet  sight  is  imperfect,  there  being  nothing  for  accurate  com- 
parison either  in  the  past  or  in  the  present.  The  sensory  portion  of  the 
organ  is  alone  properly  answered,  and  color  perception  is  the  only  correct 
result.1 

In  telegraphy  it  is  not  necessary  to  possess  an  uncorrelative  difference 
in  the  form  of  apparatus  to  be  acted  upon  by  an  artificial  division  of  a 
certain  alphabet.  As  the  resultants  are  only  modifications  of  each  other, 
they  necessitate  but  corresponding  changes  in  the  working  machinery.  If 
there  is  a  wish  to  attempt  a  higher  grade  of  a  similar  stimulus,  the  appa- 
ratus is  so  modified  as  to  allow  the  record  to  be  correctly  produced.  The 
tactile  apparatus  is  one  form  of  telegraphic  machinery  destined  to  receive 

1  It  may  be  of  importance  to  note  that  there  has  been  a  distinction  made  in  the 
terms  "visual  apparatus"  and  "  organ  of  sight."  This  has  been  intentional.  By 
"  visual  apparatus"  is  meant  the  peripheral  and  the  central  sensory  nerve  expansions, 
with  the  connecting  sensory  nerve-fibres,  i.  e. ,  the  ocular  or  receiving  retina,  the  cere- 
bral or  discharging  retina,  and  the  connecting  sensory  fibre  (so  named  optic  nerve)  ; 
whereas,  by  "  organ  of  sight"  is  designated  the  visual  apparatus  in  combination  with 
the  entire  ocular  appendages — the  muscles,  the  media,  the  tunics,  etc.  These  dis- 
tinctions apply  as  well  to  the  other  special  senses. 


102 


Oliver,  A  Correlation  Theory  of  Color-perception. 


[Jan. 


its  impressions,  whilst  the  visual  apparatus  is  another  form  of  the  same 
machinery  intended  for  the  receipt  of  the  same  character  of  impressions  ; 
each  in  itself  a  simple  mechanism,  not  possessing  differentiating  power, 
but  merely  capable  of  response  when  properly  acted  upon.  It  would  be 
foolish  to  assert  that  there  may  be  special  divisions  of  peripheral  tactile 
nerves  especially  adapted  for  the  three  empirical  sensory  impressions — 
cold,  warm,  and  hot ;  then  to  make  an  artificial  gross  division  of  caloric 
into  several  arbitrary  parts,  and  say  that  the  different  varieties  of  results 
are  the  productions  of  differences  in  grade  and  amount  of  action  upon  each 
or  all  of  these  fibres  (that  the  actions  of  natural  fixed  stimuli  cause  addi- 
tions and  subtractions  of  action  in  unknown  degrees  upon  organisms  of 
elective  power).  Yet  here  is  Young's  theory  applied  to  the  sense  of 
touch.  A  theory  slightly  modified  by  such  great  minds  as  Maxwell  and 
Helmholtz ;  accepted  and  held  almost  without  question.  Or  how  ridicu- 
lous to  say  that  there  are  three  tactile  substances  acted  upon  and  produc- 
ing three-paired  primary  tactile  sensations,  each  peforming  its  duty  in  a 
sort  of  give-and-take  manner,  yet  at  an  utter  loss  of  reasoning  to  tell 
which  gives  and  which  takes.  Here  is  the  wonderfully  ingenious  theory 
of  Hering  considered  from  a  tactile  point  of  view.  A  theory  framed  and 
thrown  to  the  world  on  account  of  the  want  of  explanation  of  complemen- 
tary color :  a  theory  blindly  followed  by  this  great  man's  satellites  and 
advocates.1  The  same  line  of  criticism  might  be  extended  to  the  senses 
of  smell  and  hearing,  in  first  supposing  several  arbitrary  odor  names,  or 
taking  the  now  existent  musical  octave,  and  then  endeavoring  to  form 
odor  and  sound  theories  to  explain  why  these  gross  recognized  differences 
in  natural  stimuli  are  smelt  and  heard.2 

Why  take  the  trouble  to  give  a  series  of  organic  elements  a  coarse  un- 
natural division  of  fibre,  in  an  effort  to  harmonize  them  with  an  arbitrary 
and  unscientific  naming  of  visible  color,  when  we  have  the  difference  of 

1  As  these  two  theories  are  the  best  known  amongst  those  that  have  been  advanced 
since  the  remotest  antiquity,  the  analogy  has  been  limited  to  them. 

2  In  the  arrangement  of  this  argument  it  might  have  been  better  to  have  compared 
these  theories  with  similar  imaginative  theorems  for  musical  sensation  and  perception, 
because  not  only  of  the  close  relationship  existing  between  the  two  senses  employed, 
but  of  the  author's  belief  that  the  special  sentient  parts  of  the  organ  of  hearing  are 
intended  for  the  reception  and  transmission  of  nerve  energies  equivalent  to  sensations 
of  sound  vibration  alone,  and  that  our  ideas  of  distance  of  sound,  direction  of  sound, 
character  of  sound,  etc.  etc.,  are  but  the  results  of  combined  perceptions  and  concep- 
tions. Nevertheless,  he  has  preferred  the  use  of  the  sense  of  touch  not  only  by  reason 
of  its  wide  remove  in  point  of  evolution  from  that  of  sight,  but  that  he  thinks  the  cor- 
relation can  be  traced  here  just  as  well.  He  also  maintains  that  the  peripheral  parts 
of  the  tactile  apparatus  are  destined  for  sensations  of  degrees  in  temperature  only, 
which  are  transmitted  as  nerve-energies  of  specific  and  relative  value  to  be  perceived 
by  the  central  organs.  Ideas  of  solidity,  weight,  etc.  etc.,  are  but  the  results  of  pre- 
viously gained  knowledge  and  associated  impressions  from  the  other  senses,  combined 
with  the  so-called  "muscular  sense,"  which  is  nothing  more  nor  less  than  an  exact 
counterpart  of  the  governing  muscles  of  the  organs  of  sight  and  hearing. 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  103 

result  dependent  upon  a  difference  in  cause  acting  upon  an  ever-ready 
material  ?  A  difference  in  the  character  of  natural  impression  affecting 
one  and  the  same  organic  element  to  a  greater  or  less  degree,  producing 
an  exact  and  equivalent  answer.  For  instance,  suppose  that  a  quantity 
of  optic-nerve  points  in  the  human  retina  should  be  exposed  to  a  beam 
of  light  of  undulations,  say,  equal  to  five  hundred  trillions  per  second, 
the  average  response  to  the  sensation  thus  produced  upon  healthy  tissue 
would  be  what  is  known  as  "  red."  Each  impinged  point  would  excite 
a  sensation  equal  to  a  specific  energy  equivalent  to  red.  Again,  suppose 
these  same  points  were  exposed  to  another  beam  of  light  of,  say,  six  hun- 
dred trillions  of  undulations  to  the  second,  they  would  cause  a  sensation 
which  would  produce  a  specific  energy  giving  the  response  of  "  green." 
Or  let  a  beam  of  light,  say  of  seven  hundred  and  thirty-three  trillions  of 
vibrations  to  the  second,  be  thrown  upon  the  same  sentient  points,  there 
would  be  "violet"  given  as  the  answer.  Each  and  every  optic-nerve 
fibre  tip  has  a  receiving  power  equal  to  its  individual  strength.  Each  and 
every  healthy  optic-nerve  filament  transmits  to  the  color  centre  for  recog- 
nition nerve  energies  equal  to  as  many  special  sensations  as  its  peripheral 
tip  is  capable  of  receiving.  The  innumerable  quantities  of  nerve  filaments 
placed  side  by  side  on  a  sheet  or  membrane  serves  to  give  greater  field, 
and  to  allow  many  colors  to  be  seen  at  one  and  the  same  time,  thus  making 
our  every-day  and  momentary  pictures.  Therefore,  in  the  author's  opinion, 
the  most  rational  theory  is,  that  color-perception  takes  place  through  each 
and  every  optic-nerve  filament.  It  consists  in  the  passive  separation  of  a 
specific  nerve  energy  equal  to  the  exposed  natural  color,  from  a  supposed 
"  energy-equivalent"  resident  in  the  peripheral  nerve  tip,  by  an  active 
chemico-vital  process  of  the  impinging  natural  color  vibration  upon  the 
sensitized  nerve  terminal.  The  separated  nerve  energy  is  transmitted  to 
the  central  terminus  of  the  filament  in  the  cerebral  retina,  where  it  is 
fully  evolved  into  such  a  condition  as  to  be  transferred  into  an  automatic 
form  of  perception  by  an  action  upon  some  unknown  contiguous  perceptive 
nerve  elements :  this  constitutes  the  consummation  of  the  nerve  energy 
force  into  the  lowest  (and  evanescent)  form  of  recognizable  color-percep- 
tion. Finally,  it  is  carried  through  similar  posts  and  stations,  though 
now  of  a  higher  value,  as  it  was  whilst  pursuing  its  course  inwards  as  a 
sensation,  until  at  last  it  is  completely  recognized  as  intelligent  color-per- 
ception in  the  higher  color  centres ;  these  higher  color  cells  being  per- 
manent in  type,  and  forming  parts  and  parcels  of  the  higher  perceptive 
cerebral  centres.  The  first  moment  that  the  primary  portion  of  this  action 
(i.  e.,  the  separation)  has  taken  place,  there  has  been  left  in  the  peripheral 
tip  of  the  primarily  impinged  sensory  filament  a  nerve-energy  material 
equal  to  the  difference  between  that  individual  nerve's  "  energy-equiva- 
lent" and  the  transmitted  nerve  stimulus.  The  healthy  peripheral  nerve 
tip  returns  to  its  "  energy-equivalent,"  or  normal  nerve  power,  the  mo- 


104         Oliver,  A  Correlation  Theory  of  Color-perception.  [Jan. 


ment  the  specific  energy  separated  by  the  received  natural  vibration  has 
been  forwarded  for  transmission  and  recognition  ;  whilst  the  transmitting 
filament  and  excited  cerebral  expansion  regain  their  normal  condition  the 
moment  the  energy  has  passed  them.  After  the  consummation  of  such 
an  action,  the  filament  is  again  ready  for  any  other  natural  color-vibration. 
The  whole  secret  of  the  theory  rests  in  the  fact,  that  all  natural  color 
stimuli  cause  definite  losses  of  nerve-energy  material,  whilst  rest  of  the 
nerve  produces  restitution  of  nerve-energy  substance.1  To  see  red,  the 
nerve  is  first  supposed  to  be  charged  to  its  normal  physiological  condition 
by  its  inherent  vitality  and  sensitizing  material.  Vibrations  of  five  hun- 
dred trillions  per  second — a  natural  red  color — are  allowed  to  be  thrown 
upon  this  sensitized  tip.  To  see  the  color,  the  peripheral  negative  (an 
unused  energy  equal  to  the  commencing  sensation  of  a  green)  must  be 
allowed  to  rest,  by  the  separation  of  a  quantity  of  nerve-force  equal  to  a 
supposed  red-energy  from  the  "  energy-equivalent,"  through  the  excitation 
of  the  impinging  ray.  This  separated  specific  energy  is  transmitted  to 
the  lower  color  centre,  where,  although  perceived,  it  is  still  more  fully 
formed  into  a  condition  fit  to  be  put  upon  record  by  certain  higher  percep- 
tive elements,  thus  constituting  the  highest  or  intelligent  perception  of 
red.  The  moment  that  the  red  energy  has  left  the  nerve-tip,  the  terminal 
is  again  charged  to  its  energy-equivalent,  and  is  ready  to  receive  any  other 
color-vibration  that  may  be  cast  upon  its  surface.  The  same  tip  is  able 
to  receive  as  many  impressions  of  natural  color  as  it  holds  similar  sensa- 
tions under  its  jurisdiction.  Each  and  every  natural  color  causes  the 
separation  of  a  specific  energy  equal  to  itself,  which  is  properly  transmitted 
and  correctly  perceived,  if  the  conducting  and  central  nerve  structures  be 
normal  and  intact. 

It  will  be  noticed  that  it  is  presumed  that  the  sensation  must  begin  in 
the  peripheral  termination  of  the  visual  apparatus  (the  ocular  retina),  be- 
cause it  is  here  that  the  primary  change  of  an  external  natural  force  into 
an  equivalent  nerve-energy  takes  place,  i.  e.,  the  conversion  of  a  natural 
impression  into  the  first  form  of  a  sensation.  This  primary  form  of  sen- 
sation is  conducted  inwardly  by  the  so-termed  "optic-nerve"  (truly  speak- 
ing, the  intermediate  connecting  link  of  the  optic-nerve),  and  spread  as 
more  thoroughly  adapted  and  as  a  finished  sensation,  upon  the  intracranial 
retina,  in  such  a  form  as  to  be  readily  converted  into  an  equivalent  per- 
ception by  the  aid  of  some  unknown  process  of  mentality.  The  sensation 
is  first  formed  peripherally  by  the  impinging  natural  impression  upon  an 
individual  nerve  tip  ;  it  is  conveyed  inwardly  as  such,  by  an  intermediate 

1  This  is  the  usual  and  normal  order  of  progression  in  the  evolution  of  a  recognized 
color-perception  from  a  natural  color-stimulus  ;  although,  as  will  be  explained,  forces 
can  originate  in  other  ways,  which  may  act  upon  any  part  of  the  visual  apparatus  or 
its  related  perceptive  tracts  and  cells,  and  thus  give  rise  to  visible  results. 


1885.]     Oliyee,  A  Correlation  Theory  of  Color-perception.  105 


connecting  optic-nerve  fibre,  and  at  last  is  evolved  upon  a  definite  portion 
of  the  intracranial  sheet  or  membrane  as  the  same  sensation,  though  now 
completely  finished  for  conversion  into  a  perception  of  an  equivalent 
value  :  in  other  words,  an  impression  of  natural  force  upon  a  special  sense 
apparatus,  causes  a  peripheral  change  of  that  natural  force  into  a  nerve- 
energy  (the  primary  form  of  the  sensation),  which  is  forwarded  to  a  posi- 
tion and  in  such  a  manner  that  it  is  converted  into  a  perception  in  certain 
definitive  perceptive  structures.  This  reasoning  is  dissimilar  in  measure 
from  that  which  would  be  employed  in  the  usual  significations  of  the 
terms  "  sensation,"  "perception,"  and  "impression,"  although  in  no  way 
does  it  allow  the  visual  apparatus  to  act  as  a  differentiating  body.  In 
these  remarks,  the  following  distinctions  between  the  terms"  impression," 
"  sensation,"  and  "  perception,"  have  been  ventured,  which  differ  some- 
what from  those  found  in  the  ordinary  books  bearing  upon  the  subject.1 

1.  An  impression.  The  impinging  of  an  extraneous  natural  force  upon 
the  peripheral  termination  of  any  sensory  apparatus.  The  action  of  an 
outer  world  and  a  receiving  material. 

2.  A  sensation.  The  action  of  a  sensory  nerve.  This  in  all  instances 
commences  peripherally,  where  a  natural  impression  is  converted  into  a 
nerve-energy  of  a  relatively  equal  power;  which  energy  is  conveyed  to  a 
position  and  evolved  into  a  condition  by  the  transmitting  and  central  struc- 
tures of  the  apparatus,  so  as  to  allow  a  recognition  by  contiguous  percep- 
tive elements.  The  work  of  a  receiving,  conducting,  and  discharging 
material. 

3.  A  perception.  The  recognition  of  a  properly  evolved  sensation  by 
an  act  of  mentality  through  the  excitation  of  definite  perceptive  structures 
in  the  cerebral  cortex  connected  in  some  way  with  the  central  terminals 
of  a  sensory  apparatus.  The  action  of  an  inner  world  and  a  discharging 
material. 

There  cannot  be  any  doubt  but  that  the  mind  must  act  in  color  percep- 
tion, or  there  would  not  be  any  visible  world.  To  perceive  color,  the 
mentality  must  take  cognizance  of  the  action  of  an  impinging  color-sen- 
sation which  has  been  ever  altering  and  becoming  higher  and  higher  in  its 
physical  and  physiological  growths,  from  the  time  it  was  first  formed  from 
a  peripheral  impression  of  natural  color-stimulus.  If  it  be  agreed  that 
the  laws  of  an  act  of  color  perception  are  similar  to  those  of  color-sensa- 
tion, although  the  character  of  the  labor  of  the  former  is  of  a  higher  order, 
it  must  be  conceded  that  physical  posts  and  stations  intended  for  the  evo- 
lution of  the  material  qualities  of  the  perceptive  agency  must  exist. 
This  implies  that  as  color-perception  has  its  regular  development  and 
growth,  it  must  necessarily  have  a  scale  of  efficiency  or  ratios  of  percep- 

1  In  these  definitions,  abnormal  and  pathological  stimuli  are  excluded. 


106         Oliver,  A  Correlation  Theory  of  Color-perception.  [Jan. 


tive  powers.  Endeavors  to  accurately  place  or  express  these  powers, 
or  even  to  give  analyses  of  their  various  strengths,  are  futile  as  long  as 
the  union  between  mind  and  body  remains  a  locked  secret.  It  may 
be  assumed,  however,  that  there  is  much  difference  between  what 
may  be  termed  intelligent  color-perception  and  automatic  color-perception; 
and  at  this  point,  at  this  gross  dissimilarity,  the  human  mind  with  its 
present  knowledge  is  compelled  to  stop.  Automatic  color-perception  (by 
some  termed  color-sensation)  is  the  primitive  form  of  the  perception, 
where  although  the  color  is  recognized,  yet  the  mentality  is  of  such  a  low 
order  that  the  perceptive  color  cells  which  have  been  primarily  impinged 
— perceptive  cells  of  evanescent  power — would  quickly  lose  their  new 
quality,  and  the  color-perception  be  forever  lost,  if  they  had  not  the  power 
of  transmitting  it  to  the  higher  color-cells  in  the  centres  where  intelligence, 
etc.,  the  creations  of  the  higher  mentality,  are  brought  into  play,  and 
which  place  it,  as  it  were,  upon  record,  so  that  it  may  be  used  in  future 
requirements.  In  this  higher  situation  the  perception  is  stamped,  the 
internal  consummation  of  the  external  force  takes  place  ;  here  it  is  that 
the  higher  color-cell  is  either  deposited  or  augmented  so  as  to  be  brought 
into  action  as  often  as  a  proper  stimulus  attacks  it ;  and  it  is  at  this  place 
that  these  very  cells  live  and  play  their  roles,  growing  fat  and  healthy 
from  use,  shrivelling  and  dying  from  inactivity.  What  may  be  the  situa- 
tion of  these  higher  cells  of  permanent  powers,  and  how  they  live,  must 
remain  unanswered  ;  for  although  physiological  experiment  and  pathology 
have  taught  the  probability  of  position  of  the  lower  forms,  they  have  thus 
far  failed  to  reveal  the  phenomena  of  individual  and  separate  existence. 
No  matter  whether  a  force  be  of  external  or  internal  origin,  if  it  either 
acts  upon  these  higher-formed  cells  or  makes  a  new  corpuscle,  it  will 
cause  intelligent  color-perception  (the  so-called  "  perception"),  because 
the  newly  formed  higher  cell  or  the  increased  material  is  in  a  proper  con- 
dition and  a  correct  situation  to  act  in  its  turn  upon  the  whole  force  of 
contiguous  mentality.  As  the  greater  part  of  this  mentality  has  been  de- 
rived from  the  accrued  results  of  the  other  sensory  organs  as  well  as  from 
the  visual  apparatus,  there  may  also  arise  an  action  of  all  of  the  other  re- 
sponsive cells,  which  response  will  cause  an  act  called  sight.  So  it  is 
with  the  other  sensory  organs  and  channels  from  the  outer  to  the  inner 
world.  Audition,  olfaction,  gustation,  and  taction,  each  may  have  added 
to  its  individual  capability  such  mental  factors  as  will  produce  hearing, 
smelling,  taste,  and  touch.  The  manifold  combinations  of  these  final  re- 
sults with  each  other  as  well  as  with  the  processes  of  the  deeper  though 
derivative  mental  forces — such  as  emotion,  volition,  intelligence — consti- 
tute the  ultimata  of  mental  activity.  The  results  of  hypnotism,  somnam- 
bulism, or  in  fact  any  of  the  so-called  disturbances  of  the  ganglion  cells  of 
the  cerebral  cortex,  conclusively  show  this  distinction.   All  this  bears  out 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  107 


the  saying  of  Epicharmus,  the  old  Greek  poet :  "  'Tis  mind  alone  that 
sees  and  hears ;  all  things  besides  are  deaf  and  blind."1 

The  questions  now  arise  :  What  is  strictly  meant  by  the  expression 
"  energy-equivalent"  ?  Why  is  it  supposed  to  reside  in  the  peripheral  ter- 
mination of  each  optic-nerve  filament  ?  What  is  its  value  ?  What  is 
understood  by  the  term  "  specific  energy"  ?  Where  is  its  residence  ? 
Why  were  these  nerve-energies  chosen  ?  What  is  meant  by  normal  con- 
dition ?  The  combined  answers  to  this  series  of  questions  may  be  given 
in  the  following  paragraphs.  At  the  peripheral  tip  of  every  optic  nerve 
filament,  there  must  be  two  separate  and  distinct  actions  in  the  receipt 
and  the  conversion  of  a  natural  color-stimulus  into  an  equivalent  nerve- 
energy.  First,  a  separation  of  a  nerve-force  physiologically  equal  to 
the  amount  of  the  natural  stimulus  of  the  impinging  extraneous  vibra- 
tion, from  the  normal  conditions  of  the  "energy-equivalent"  resident 
in  the  tip  of  the  impressed  nerve  ;  and  secondly,  a  return  to  the  now 
lowered  remaining  nerve-energy  material,  of  an  energy  matter  equal 
to  the  separated  amount  of  force,  the  moment  the  natural  color-stim- 
ulus is  withdrawn,  thus  changing  the  remaining  energy  to  the  normal 
energy-equivalent.  What  this  force  is,  and  how  it  is  formed,  sepa- 
rated, propagated,  and  reformed  are  all  difficult  problems  to  attempt 
to  answer.  Many  thoughts,  such  as  chemical  decomposition,  molecular 
vibration  or  oscillation,  direct  transmission  of  vital  force,  suggest  them- 
selves, but  no  one  can  positively  say  which  one  of  these,  or  whether  all, 
or  even  some  other  yet  unknown  force,  can  be  considered  as  the  true  sen- 
sory actor,  until  discriminating  instruments  can  be  brought  to  play  upon 
the  living  and  acting  organism.  It  is  probably  of  a  purely  chemico-vital 
character,  placed  in  such  a  situation  as  to  permit  stimulation  of  natural 
color  upon  it.  It  is  not  possible  to  give  it  any  determinate  and  fixed 
ratio  of  value,  because  this  must  be  dependent  upon  the  vitality  and 
strength  of  each  optic  nerve  filament.  Each  tip  is  born  into  the  world 
and  exposed  to  light  with  a  definite  amount  of  developed  physical  mate- 
rial just  as  any  hereditary  or  congenital  feature,  a  foot,  a  hand,  etc., 
and  it,  through  the  same  amount  of  physiological  action  as  another  optic- 
nerve  tip  not  so  well  developed,  gives  greater  and  finer  results  than  its 
fellow  ;  thus  stamping  that  individual  optic-nerve  tip  in  its  peculiar  power 
of  action.  Again,  if  two  tips  have  primarily  the  same  amount  and  the 
same  grade  of  physical  structure,  their  life  histories  may  be  such,  in  refer- 
ence to  situation,  position,  exercise,  etc.,  that  they  will  each  develop  and 

1  The  fact  that  the  reader  dissents  from  this  division  of  action  in  vision,  and  desires 
rather  to  believe  in  the  terms  "  impression,"  "  sensation,"  and  £'  perception"  as  gener- 
ally received,  does  not  aifect  the  correctness  of  the  theory  at  all.  The  author  gives 
but  his  personal  beliefs  as  to  the  use  of  the  expressions,  which  might  with  equal  pro- 
priety be  abolished  by  any  disbeliever,  and  yet  the  foundation  of  the  fabric  remain 
secure  and  untouched. 


108         Oliver,  A  Correlation  Theory  of  Color-perception.  [Jan. 


have  far  different  sensory  material  and  power.  Roughly  speaking,  the 
quotient  of  value  of  each  individual  "  energy-equivalent"  is  equal  to  the 
subjective  sensation  (with  consequent  perception)  of  as  pure  and  as  color- 
less an  energy  as  its  individual  past  objective  sensations  would  make  if 
they  had  been  extraneously  combined  as  separate  color  vibrations  to  form 
a  natural  impure  beam  of  light  (some  impure  white). 

By  the  term  "  specific-energy"  is  meant  a  specific  amount  of  sensory 
nerve  force  which  has  been  primarily  separated  from  an  energy-equivalent 
resident  in  the  peripheral  terminus,  by  the  action  of  an  impression  of  natu- 
ral color.  This  separated  energy  always  bears  a  definite  relation  to  the 
amount  of  natural  color- vibration.  After  separation,  it  is  evolved  into  a 
higher  grade  of  action  during  its  passage  along  the  transmitting  apparatus, 
until  at  last,  it  is  spread  as  an  almost  fully  developed  force  in  a  relatively 
similar  position  upon  a  cerebral  membrane  ready  to  be  still  further 
charged  to  a  sufficient  vitality  to  act  and  to  be  acted  upon  by  some  men- 
tal equivalent. 

The  reason  of  the  choice  of  these  two  forms  of  this  special  sensory  force 
must  be  palpable  after  the  above  explanations  ;  they  serving  as  full  an 
answer  to  the  proposed  questions  as  any  other  that  might  be  added. 
Besides,  such  a  theoretical  designation  of  nerve-energy  admits  of  much 
more  convenient  practical  testimony  in  its  behalf,  than  any  other  form  of 
speculative  argument  bearing  upon  the  subject. 

The  last  question,  "  What  is  meant  by  'normal  condition'  ?"  is  almost 
self-answerable.  It  was  chosen,  however,  to  serve  as  an  expression  of 
difference  to  the  specific  term  "  energy-equivalent,"  as  expressing  a  mere 
physiological  rest,  just  as  would  be  found  in  the  normal  condition  of  any 
other  acting  body.  In  this  distinction,  it  must  be  understood  that  there 
may  be  a  primary  excitation  of  this  material  by  some  internal  force,  with 
a  resultant  corresponding  physiological  action,  just  as  freely  as  if  the 
"  energy-equivalent"  had  been  stimulated. 

This  theory  has  the  following  theorems  of  natural  color  for  its  basis  : — 1 

1.  The  general  convenient  adoption  of  the  seven  so-called  primary 
colors,  or  of  the  solar  spectrum  being  made  of  three  graduated  overlaying 
spectra  must  be  discarded,  as  these  are  nothing  more  nor  less  than  crude 
visual  and  mental  distinctions  made  through  the  want  of  perfect  physical 
condition  and  physiological  ability. 

2.  A  difference  in  kind  of  undulation  makes  a  change  in  natural  color, 
and  every  such  change  must  be  called  a  "  primary  natural  color"  or  a 
"pure  natural  color"  ;  on  account  of  its  being  the  representative  of  a 
specific  character  of  vibrations  totally  different  and  distinct  from  any 
other  primary  natural  color.    There  are  as  many  separate  primaries  or 

1  By  "  natural  color"  is  meant  every  species  of  independent  and  combined  light 
vibration  (except  total  synthesis),  in  contradistinction  to  ''visible''  or  "sensory 
color,"  which  is  a  mere  visual  and  mental  exponent  of  such  wave  lengths. 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  109 

pure  colors  as  there  are  difference  in  undulations  between  the  extremes  of 
color-vibration. 

3.  A  "  secondary  natural  color"  or  a  "tone"  is  the  result  of  the  addi- 
tion of  any  two  pure  natural  colors  or  primaries. 

4.  A  "multiple  natural  color"  is  the  result  of  the  addition  of  two  or 
more  tones,  or  of  more  than  two  pure  natural  colors. 

5.  Colorless  light  is  the  compound  of  all  natural  color,  the  origin  of  all 
separated  natural  color  vibrations.  The  purest  example  may  be  repre- 
sented by  the  synthesis  of  a  resultant  spectrum  produced  from  the  com- 
bination of  all  of  the  spectra  of  all  of  the  natural  elements  in  all  possible 
conditions.  To  human  knowledge,  there  is  no  single  natural  body  which 
contain  all  of  the  natural  elements ;  consequently  to  human  knowledge, 
there  is  no  individual  body  that  can  give  rise  to  pure  colorless  light. 
Every  light-giving  source,  such  as  a  sun,  electricity,  chemical  and  animal 
change,  gives  a  definite  color-spectrum  equal  to  its  constituent  elements. 
Hence  there  must  be  two  varieties  of  colorless  light,  pure  and  impure.1 

6.  By  an  inherent  synthetical  power,  every  light-giving  source  gathers 
and  collects  all  of  its  individual  elemental  spectra  into  a  compound  natural 
energy.  Portions  of  this  energy  are  propagated  into  all  free  space  as  un- 
dulations equivalent  to  those  of  invisibly  impure  and  visibly  impure  color- 
less light.  These  vibrations  upon  being  received  by  a  natural  object,  are 
either  fully  absorbed,  totally  reflected,  or  broken  into  two  portions,  the 
absorbed  and  the  reflected  ;  this  being  dependent  upon  the  nature  of  the 
impinging  beam  and  the  character  of  the  impinged  object ;  the  reflected 
portion  gives  the  natural  color  to  the  object.  The  amount  of  the  separat- 
ing action  is  dependent  upon  the  relation  existing  between  the  active 
power  of  the  impinging  beam  and  the  passive  resistance  of  the  body.  A 
slightly  impure  beam  is  able  by  its  relative  action  upon  innumerable 
bodies  to  separate  itself  into  innumerable  colors,  whereas  a  decidedly  im- 
pure beam  separates  only  the  varying  tints  and  shades  of  its  own  kind.2 

7.  Pure  complementary  color.  Every  natural  color  has  its  complemen- 
tary, to  which,  if  it  be  combined  in  certain  ways  by  a  natural  object,  gives 
either  pure  white  or  pure  black. 

Pure  white  is  caused  by  the  simultaneous  reflection  in  a  definite  direc- 
tion of  any  two  pure  complementary  colors,  or  of  any  even  multiples  of 
pure  complementary  colors,  from  an  impinged  natural  object.  Hence, 

1  The  impure  white  light  of  the  earth's  sun  is  an  impure  colorless  beam,  the  repre- 
sentative of  the  solar  constituents. 

2  As  a  matter  of  course,  the  visual  apparatus  cannot  see  invisibly  impure  light. 
Such  light  falls  upon  the  sentient  parts  of  the  retiDa  as  well  as  upon  any  other  natural 
body  which  absorbs  and  reflects.  The  amount  of  reflection  gives  to  these  sentient 
tips  their  natural  color.  They  are  fitted  to  respond  only  to  energies  equal  to  imping- 
ing reflected  rays.  (All  transmitted  rays  to  be  seen,  must  have  surfaces  or  points  of 
reflection.) 


110         Oliver,  A  Correlation  Theory  of  Color-perception.  [Jan. 


pure  white  is  a  positive  or  a  visible  tone,  of  which  there  may  be  innume- 
rable varieties. 

Pure  black  is  caused  by  the  simultaneous  absorption  of  any  two  pure 
complementary  colors  or  of  any  even  multiple  of  two  pure  complementary 
colors,  by  the  passive  action  of  an  impinged  natural  object.  Hence,  pure 
black  may  be  considered  as  a  negative  or  an  invisible  tone,  of  which  there 
may  be  innumerable  varieties.  It  is  not  a  color,  and  has  darkness  for  its 
equivalent. 

8.  Impure  complementary  color.  Every  natural  color,  primary, 
secondary,  or  multiple,  has  innumerable  impure  complementaries.  If 
there  should  be  a  combination  in  certain  ways  of  any  one  or  more  of  these 
natural  colors  with  one  or  more  of  its  impure  complements,  there  will  re- 
sult an  impure  white  or  an  impure  black — a  tint  or  a  shade. 

A  tint  is  the  simultaneous  reflection  in  the  same  direction  of  two  or 
more  impure  complementary  colors,  from  an  impinged  natural  object. 
The  preponderant  wave  serves  as  a  basis  for  the  color. 

A  shade  in  the  simultaneous  absorption  of  two  or  more  impure  comple- 
mentary colors1  by  the  passive  action  of  an  impinged  natural  object. 

9.  Darkness  :  two  conditions. 

a.  Produced  by  the  interference  of  two  or  more  series  of  undulations. 
The  rising  phase  of  the  one  exactly  corresponds  in  position  and  time  with 
the  sinking  phase  of  the  other ;  thus  they  neutralize  each  other,  and  give 
rise  to  the  loss  of  positive  color.  It  may  be  designated  as  positive  undula- 
tions so  interfering  as  to  give  negative  results.  Of  these,  there  may  be 
many  varieties. 

b.  True  absence  of  light  undulation.  Here  there  are  no  stimuli  produc- 
tive of  color  ether-waves,  hence  no  results,  either  positive  or  negative. 
This  condition  is  directly  opposed  to  pure  colorless  light. 

Physiological  Research  As  before  intimated,  in  the  human  sys- 
tem, every  special  sense  apparatus  has  three  separate  parts.  First,  a  peri- 
pheral expansion  intended  for  the  reception  of  natural  vibration  equal  to 
its  powers  of  primary  sensation.  Second,  a  series  of  telegraphic  com- 
munications, inclosed  and  insulated,  separated  and  adapted  for  the  trans- 
mission and  the  partial  evolution  of  equivalent  nerve  energies.  Third,  a 
central  expansion,  upon  which  is  spread  the  received  result,  ready  to  be 
fully  evolved  and  transformed  into  a  perception  by  a  contiguous  nerve 
material  endowed  with  the  power  of  mentality.  The  visual  apparatus  is 
but  one  of  these  forms  ;  a  sensory  nerve  development  adapted  for  impres- 
sions of  color ;  and  from  this  standpoint  it  must  be  studied.  Naturally, 
inquiry  would  be  made  for  methods  of  determining  the  comparative  rela- 
tions existing  between  the  exciting  stimuli  and  the  degree  of  sensory 
power  of  the  apparatus.  Mathematically,  this  has  been  found  totally  in- 
adequate ;  so  that  at  present,  not  possessing  any  absolute  data  for  ratios 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  Ill 


of  equivalence  between  the  strength  of  the  impinging  beam  and  the  ap- 
preciation or  value  of  sensation  of  the  receiving  fibre,  except  those  based 
upon  physiological  investigations  and  clinical  experience,  these  have  been 
deemed  sufficient  for  a  time  at  least,  to  endeavor  a  proper  enunciation  of 
the  theory.  The  question  of  the  value  of  theorizing  as  to  the  mod?.is 
operandi  falls  to  the  ground,  the  moment  that  it  is  unbiasedly  considered 
that  having  but  one  premise  fixed  to  the  equation  no  conclusion  can  be 
arrived  at.  Theoretically,  the  beam  of  light  of  the  least  number  of  vibra- 
tions should  be  that  of  the  easiest  recognition,  but  then  the  questions  arise — 
Does  not  such  a  beam  cause  less  sensory  disturbance  ?  Does  it  not  excite 
the  filament  the  least?  Would  not  a  stronger  natural  impression  give  a 
correspondingly  stronger  nerve-energy?  What  relation  may  the  intensity 
of  the  natural  color  vibrations  have  upon  the  ease  of  impression  ?  All  of 
these  are  serious  questions,  which  must  remain  unanswered  until  ingenious 
instruments  of  such  precision  are  made,  that  can  with  unerring  accuracy 
and  the  utmost  delicacy  give  the  actual  rates  of  known  impression  and 
passage  of  equivalent  nerve-energies.  All,  therefore,  that  can  be  reason- 
ably presumed,  is,  that  there  must  be  a  normal  condition  to  which  the 
nerve  filament  must  return  after  each  individual  impression  has  been  con- 
veyed. This  has  been  brought  forward  more  at  length  in  the  previous 
part  of  the  paper,  and  upon  it  the  whole  superstructure  rests.  In  this 
section  of  the  subject  endeavors  shall  be  made  to  study  and  give  some 
physiological  explanations  for  its  choice,  and  add  a  few  reasons  why  its 
probability  may  be  entitled  to  belief.  After  much  deliberation,  it  has 
seemed  best  to  consider  the  different  results  under  the  following  heads  : — 

First.  Color-perception  as  produced  by  color-sensation  commenced  in 
the  macular  region  of  the  ocular  retina. 

Second.  Color-perception  as  caused  by  color-sensation  primarily  formed 
in  the  circummacular  region  of  the  ocular  retina. 

Third.  Color -perception  directly  resulting  from  provoked  remaining 
nerve-energies.    Subjective  after-color  {so-called  complementary  color). 

Fourth.  Color -perception  caused  by  the  action  of  internal  stimuli  upon 
nerve-energies  which  have  not  been  lowered  by  any  preceding  act.  Sub- 
jective color. 

First.  Color-perception  as  produced  by  color-sensation  commenced  in 
the  macular  region  of  the  ocular  retina. ,  From  time  to  time  experiments 
have  been  instituted  in  various  ways  to  determine  the  qualitative  and 
quantitative  limits  of  normal  color-perception  derived  from  color-sensation 
primarily  made  at  the  macula  lutea.  Those  for  the  determination  of  the 
latter  have  been  the  more  numerous,  and  these  have  been  limited  to  a  few 
of  the  more  important  and  valuable  color  differences.  As  might  be  ex- 
pected from  theory,  experimentation  has  revealed  that  although  all  indi- 
vidual macular  regions  have  definite  relative  powers  with  each  other,  yet 
no  two  possess  exactly  the  same  amount  of  color-sensation  ;  thus  con- 


112         Oliver,  A  Correlation  Theory  of  Color-perception.  [Jan. 


clusively  showing  that  each  has  a  different  amount  of  nerve-tissue  and 
nerve-energy.  This  can  be  understood  when  it  is  considered  that  the 
great  varieties  of  physical  differences  in  similar  normal  organs,  must 
necessarily  give  proportionate  differences  in  normal  physiological  action. 
Consequently,  here  it  has  involved  the  use  of  standards  for  a  proper  solu- 
tion of  the  average  strength  of  color-vibration  upon  those  optic-nerve 
filaments  which  are  deemed  by  all  physiologists  to  be  of  the  highest 
physical  organization — the  filaments  resident  in  the  yellow-spot.  Briefly, 
the  order  of  the  standards  for  five  of  the  most  important  colors  have  been 
red,  yellow,  blue,  green,  and  violet,  showing  that  a  natural  red  vibration 
excites  an  optic-nerve  filament  the  quickest,  followed  by  the  others  in  the 
order  given  above.1  At  present  it  will  not  be  necessary  to  offer  any  ex- 
planation why  these  colors  follow  each  other  with  such  regularity.  Suffice 
it  to  say,  that,  as  before  intimated,  it  can  never  be  hoped  to  gain  a  proper 
solution  to  the  problem  until  vital  energies  can  be  reduced  to  mathematical 
certainties,  although  an  adequate  answer,  based  upon  the  combined  results 
of  physiological  research  and  pathological  study,  will  be  reserved  for  the 
concluding  paper. 

Second.  Color-perception  as  caused  by  color-sensation  primarily  formed 
in  the  circummacular  region  of  the  ocular  retina.  Really  no  sharp  line 
can  be  drawn  between  these  two  headings,  as  one  is  a  gradual  lessening  of 
the  other  ;  but  as  the  experiments  have  been  dealing,  in  the  investigation 
pursued  in  this  connection,  with  the  furthermost  limits  of  the  generally 
used  portion  of  the  ocular  retina,  in  contradistinction  to  those  of  direct 
use,  it  has  seemed  better  to  make  the  classification  so  as  to  have  a  com- 
parison between  the  weakest  and  the  strongest  filaments  of  the  nerve. 
Two  plans  were  adopted:  One,  to  consist  in  the  study  of  the  ordinary 
visual  fields,  and  the  other  in  investigations  as  to  the  possible  recognition 

1  This  lias  been  partially  determined,  and  will,  probably,  be  continued  by  the  writer 
in  experiments  differing  somewhat  in  detail  of  method  from  any  others  with  which  he 
is  acquainted.  An  emmetropic  eye  with  good  color  vision  is  placed  at  the  extremity 
of  a  blackened  tube  six  metres  in  length  by  ninety  millimetres  square.  No  light  is 
permitted  to  enter  the  eye,  except  from  the  opposite  end  of  the  tube,  and  this  through 
a  graduated  double  shutter,  practically  similar  in  all  respects  to  the  author's  color- 
sense  measure  (description  in  Archives  of  Ophthalmology,  vol.  x.  No.  4,  p.  438),  with 
the  exception  that  transmitted  light  is  used  instead  of  reflected,  as  in  his  previous  ex- 
periments ;  this  being  accomplished  by  the  substitution  of  thin,  transparent  plates  of 
colored  glass,  or  gelatine,  in  the  opening  between  the  shutters,  for  the  squares  of  colored 
paper  previously  employed.  The  movable  slides  in  the  newly  adapted  color-sense 
measure  are  slowly  separated,  and  the  area  of  exposed  color  registered  the  moment  it 
is  properly  designated.  This  plan  is  pursued  in  such  a  manner  that  there  can  be 
nothing  but  a  certain  amount  and  kind  of  color-stimulus  to  affect  any  desired  region 
of  optic-nerve  filaments.  To  complete  the  experiments,  and  to  make  them  of  fixed 
value,  there  should  be  some  mechanical  device  constructed  by  which  the  shortest  time 
necessary  for  the  perception  of  the  color  could  be  accurately  determined  and  registered. 
Valuable  results  might  also  be  obtained  by  diminishing  the  illumination  as  in  the  ex- 
periments of  Bull. 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  113 


of  all  of  the  colors  (equal  to  the  power  of  the  individual  macula  lutea 
region  under  observation),  in  the  periphery,  by  increase  in  illumination  or 
in  quantity  of  color  exposed.1  As  far  as  gone,  all  of  these  showed  the 
following  results  : — 

1  It  has  not  been  thought  necessary  to  accurately  describe  the  proposed  methods, 
but  merely  to  state  the  character  of  experiment  with  a  description  of  the  instruments 
in  use.  For  the  first  series,  perimetric  observations  are  made  with  areas  of  reflected 
color  upon  both  black  and  white  surfaces,  as  well  as  examinations  of  the  same  char- 
acter, by  the  employment  of  transmitted  color-stimulus  alone.  This  latter  method  is 
deemed  worthy  of  full  description,  not  that  the  device  of  instrument  is  the  best,  but 
that  the  plan  in  itself  is  probably  the  only  proper  way  to  obtain  accuracy  in  the  size 
and  extent  of  the  different  visual  fields.  In  a  large  darkened  box  with  a  circular 
opening  cut  into  one  of  its  sides,  there  is  placed  a  normal  emmetropic  eye,  at  about 
thirty  centimetres  distance  from  a  small  roughened  wooden  button  fastened  against 
the  upper  end  of  a  narrow  flat  glass  rod  so  arranged  that  both  the  eye  in  the  box  and 
the  button  in  the  centre  of  the  open  area  will  be  situated  on  the  level  with  each  other. 
This  window  is  of  much  greater  size  than  any  normal  visual  field.  A  piece  of  paste- 
board several  times  larger  than  the  opening  in  the  box  is  held  against  the  window.  In 
the  centre  of  this  pasteboard  screen  there  is  a  hole  of  one  centimetre  square,  in  which 
can  be  placed  thin  sheets  of  colored  glass  or  gelatine.  As  many  pieces  of  color  may 
be  used  as  desired.  By  sliding  the  large  pasteboard  card  so  that  its  central  hole  may 
be  allowed  to  perform  excursions  in  all  directions  from  the  periphery  of  the  now 
covered  window  to  its  centre  (which  centre  is  made  visible  to  the  eye  within  the 
darkened  chamber  by  the  rubbing  of  the  wooden  button  with  a  piece  of  stick  phos- 
phorus), the  hole  in  the  immense  shutter  is  caused  to  act  as  a  definitely  sized  area  of 
movable  transmitted  color  stimulus.  The  moment  the  color  is  recognized,  as  it  is 
brought  inwards,  its  distance  from  the  luminous  button  is  measured,  so  that  when  the 
circle  is  completed,  the  different  distances  can  be  registered  upon  small  memorandum 
slips  ruled  to  proportionate  values  of  space.  As  many  different  color  fields  as  desired 
can  thus  be  taken,  and  small  registers  kept  for  future  reference  and  accurate  compari- 
son. The  objections  as  to  the  methods  being  crude,  cumbersome,  tiresome  to  the 
patient  and  surgeon,  tbe  difficulty  of  working  the  instrument,  etc.,  might  be  easily 
overcome  by  the  substitution  of  adaptations  of  better  construction.  In  the  studies  pur- 
sued in  this  paper,  all  this  would  be  but  afterthoughts,  as  here  it  is  but  desired  to  get 
a  working  instrument  of  sufficient  capability  to  give  proper  answers  to  the  experi- 
ments. The  advantage  of  the  plan  must  be  manifest  in  the  fact  that  there  is  no  other 
stimulus  present  except  that  of  the  desired  color  and  a  faintly  luminous  spot  of  just 
sufficient  visibility  to  keep  the  optic  nerve  fibres  of  the  macula  lutea  fixed  in  a  position 
to  preserve  proper  steadiness  of  the  globe. 

The  second  series  of  experiments,  where  it  is  designed  to  study  the  comparative 
strengths  of  the  most  peripheral  and  the  central  distribution  of  optic  nerve  fibres  in 
the  ocular  retina,  have  been  partially  attained  and  will  be  probably  accomplished  by 
putting  the  eye  in  a  darkened  chamber.  The  macula  lutea  will  be  kept  fixed  upon  a 
small,  white,  faintly- luminous  object  consisting  of  the  passage  of  common  daylight 
through  a  piece  of  uncolored  translucent  glass  placed  in  a  hole  one  millimetre  square 
cut  in  one  wall  of  the  chamber.  In  a  position  corresponding  with  the  most  periphe- 
rally used  parts  of  the  retina  (£.  e.,  the  outer  horizontal  meridian  of  the  visual  field), 
thin,  transparent  plates  of  colored  glass  or  gelatine  of  known  values  are  to  be  placed 
in  an  opening  ninety  millimetres  square  cut  in  the  wall  of  the  chamber  in  which  the 
central  hole  is  pierced  ;  this  opening  can  be  changed  in  position  to  correspond  with 
each  case.  In  this  opening  there  is  a  movable  slide  of  the  same  character  as  in  the 
author's  color-sense  measure,  by  the  working  of  which,  any  desired  amount  of  color 
surface  may  be  impinged  upon  by  direct  and  indirect  beams  of  sunlight  of  greater  and 
No.  CLXXVII._Jan.  1885.  8 


114 


Oliver,  A  Correlation  Theory  of  Color-perception. 


[Jan. 


1.  By  the  same  amount  of  daylight,  the  superposition  of  a  definitely 
sized  area  of  unglazed  reflected  color  upon  a  dead  black  surface,  gives  the 
largest  visual  field  to  white,  followed  by  yellow,  blue,  red,  and  green  in 
the  order  named. 

2.  By  the  same  amount  of  daylight,  the  superposition  of  a  definitely 
sized  area  of  unglazed  reflected  color  upon  a  white  surface,  gives  the 
largest  visual  field  to  yellow,  followed  by  blue,  red,  and  green  in  the  order 
named.1 

3.  Perimetric  observations  upon  black  backgrounds,  show  that  wTith 
equal  illumination,  all  reflected  colors  undergo  definite  changes  during 
their  passage  across  the  fields  towards  macular  fixation. 

The  following  is  the  order  for  those  experimented  with  :  A  definite 
area  of  white  first  gives  a  peripheral  sensation  of  gray,  which  gradually 
passes  to  white.  The  same  size  of  yellow  impression,  first  appears  as 
gray,  then  white,  then  lemon-colored,  and  at  last  yellow.  Blue -first 
appears  as  gray,  and  successively  passes  to  white,  bluish,  and  blue.  Red 
first  shows  itself  as  gray,  then  white,  followed  by  orange,  salmon-color, 
and  red.  Green  first  appears  as  gray,  then  white  (sometimes  bluish),  and 
then  greenish,  before  it  gets  to  its  true  color. 

4.  In  perimetric  observations  with  reflected  color  upon  a  white  back- 
ground, the  same  phases  of  color-change  are  undergone  as  in  similar  ex- 
greater  intensity,  at  last  supplanted  by  gauged  intensities  of  electric  light.  These 
beams  are  made  to  pass  through  a  blackened  tube  six  metres  in  length  by  ninety  milli- 
metres square,  placed  on  the  outside  of  the  chamber ;  the  extremity  of  the  tube  being 
fastened  against  the  large  eccentric  opeuing  containing  the  different  colored  plates. 
This  contrivance  enables  us  to  expose  to  the  peripheral  portion  of  the  observing  retina, 
graduated  intensities  of  chosen  colors.  Notes  of  the  size  of  the  color  stimulus  and 
of  its  intensity  will  be  taken  as  soon  as  the  color  is  properly  called.  A  ready  compari- 
son between  the  qualities  of  the  same  color  as  perceived  through  the  peripheral  fibres 
of  the  ocular  retina  and  through  the  macular  fibres  of  the  same  ocular  retina,  will  be 
made  by  putting  a  similarly  colored  piece  of  glass  or  gelatine  as  has  been  used  in  the 
large  eccentric  opening,  in  the  place  of  the  plain  translucent  glass  used  for  macular 
fixation,  and  giving  to  it  the  same  amount  of  illumination  as  has  been  used  for  the 
peripheral  color.  To  estimate  the  proportionate  physiological  values  of  the  most 
peripheral  and  the  macular  optic-nerve  filaments,  more  and  more  surface  of  the  eccen- 
trically seen  area  will  be  exposed  until  the  macular  and  the  peripheral  colors  are 
determined  to  be  as  alike  each  other  as  can  be  gotten.  (This  plan  is  but  a  modifica- 
tion of  that  of  Charpentier.  Snellen,  Landolt,  and  Aubert  have  experimented  in  other 
ways.)  After  the  establishment  of  the  visual  results,  valuable  information  as  to  the 
order  of  peripheral  loss  of  colors  could  be  easily  gotten  in  a  series  of  converse  experi- 
ments by  mathematical  diminution  of  color  intensity  and  area. 

1  As  black  is  not  a  color,  its  relative  situation  was  not  placed  in  the  list,  although  a 
similar  area  of  it  upon  a  larger  surface  of  white  was  tried,  which  showed  a  projected 
position  of  the  unimpinged  optic-nerve  filament  into  the  visual  field.  This  area  of 
defect  was  made  known  far  more  peripherally  than  the  places  of  primary  receipt  of 
any  of  the  color  vibrations,  on  account  of  its  being  inclosed  in  a  space  of  recognized 
white  stimulus. 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  115 


periments  upon  a  black  background  ;  every  color  tried,  with  the  exception 
of  white,  first  appears  as  an  area  of  non-impression.1 

5.  When  visual  fields  are  produced  in  the  same  amount  of  daylight,  by 
the  use  of  transmitted  color,  the  largest  area  is  that  of  white,  followed 
by  yellow,  blue,  red,  and  green. 

6.  As  far  as  investigations  have  gone,  the  following  may  be  laid  down 
as  a  rule.  By  increased  light  stimulus  all  of  the  different  colors  responded 
to  by  optic  nerve  filaments  in  an  individual  macular  region  can  be  recog- 
nized when  exposed  to  the  most  peripherally  used  elements  of  the  same 
retinal  area.2 

Third.  Color-perception  directly  resulting  from  provoked  remaining 
nerve  energies.  Subjective  after  color  (so-called  complementary  color). 
The  term  complementary  color  has  been  avoided  because  it  does  not 
express  the  true  condition  of  things  ;  it  only  shows  that  there  is  a  color 
which  appears  to  be  the  complementary  of  another  color  previously  seen. 
Therefore  in  consequence  of  a  wish  to  give  a  precise  designation  for  the 
character  or  kind  of  action  as  well  as  one  for  the  state  of  existence  of  the 
working  material,  in  the  place  of  a  term  which  is  merely  indicative  of  a 
recognizable  symptom,  the  above  expression  has  been  substituted. 
Possibly  it  might  have  been  advisable  to  have  placed  this  part  of  the  sub- 
ject under  the  heading  of  the  so-called  color-blindness,  because  both  con- 
ditions are  nothing  more  nor  less  than  true  species  of  each  other.  As  will 
be  explained,  the  former  is  a  momentary  faulty  answer,  the  resultant  of 
imperfect  physiological  work,  through  normal  physical  incapability ; 
whilst  the  latter  is  a  permanent3  faulty  answer,  the  resultant  of  imper- 
fect physiological  work  through  abnormal  physical  incapability.  On 
account  of  "  complementary-color"  being  as  universal  as  vision  itself,  it 
has  assumed  a  similar  physiological  basis,  and  must  be  considered  under 

1  This  is  readily  explained.  In  this  experiment  we  are  dealing'  with  a  white  back- 
ground, which  is  the  largest  visual  color-field.  All  the  other  color-fields  are  propor- 
tionately smaller ;  hence  the  boundary  of  the  white  field  must  be  the  peripheral  limits 
of  color-vision.  A  small  white  area  is  first  seen  as  gray  at  the  border  of  its  white 
field,  because  at  this  point  it  necessarily  must  give  its  first  weak  sensation.  The  other 
color  areas  have  a  certain  space  of  peripheral  white  color  vision  to  travel  over  before 
they  commence  to  be  recognized  ;  consequently,  the  superposition  of  one  of  these 
natural  colors  anywheres  in  this  space,  must  necessarily  take  away  the  vision  for 
white  in  the  superimposed  position,  and  yet  fail  to  give  any  impression  whatever. 
Hence  as  a  consequence,  there  is  an  area  of  subjective  darkness — an  area  of  unrecog- 
nized color-stimulus. 

2  The  author's  experiments  in  this  direction  have  not  been  completed.  They  have 
been  limited  to  the  mere  question  of  recognition  of  the  five  color-differences — white, 
yellow,  blue,  red,  and  green.  He  has  partially  determined  that  the  comparative 
values  of  the  experimented  colors  are  in  the  order  as  given  above. 

3  By  "  permanent"  is  meant  a  time  corresponding  to  the  continuance  of  the  causa- 
tive pathological  structural  change. 


116         Oliver,  A  Correlation  Theory  of  Color-perception.  [Jan. 


the  physiological  laws  of  the  visual  apparatus.    Hence  it  has  been  placed 
here.    In  order  to  facilitate  the  studies  in  this  branch,  the  results  and 
reasonings  of  previous  investigators  have    been  combined  with  some 
additional  experiments  and  analyses,  and  from  these,  certain  suppositions 
as  to  causation  have  been  framed.    As  said  in  the  other  headings,  it  does 
not  seem  necessary  to  give  each  individual  example  of  research  ;  for, 
besides  being  burdensome,  it  would  but  add  much  unnecessary  detail, 
where  resultant  averages  could  be  readily  formulated  and  briefly  given. 
It  must  be  granted  that  all  such  changes  are  necessarily  of  a  purely  sub- 
jective type — a  momentary  alteration  of  physical  structure  causing  a 
consequent  relatively  faulty  answer.    The  exciting  stimulus  may  be  either 
peripheral  or  central — external  or  internal ;  it  does  not  matter  which,  as 
long  as  there  is  a  passing  fault  in  the  machinery,  there  will  be  a  corres- 
ponding fault  in  the  product.    This  gives  the  first  grand  division  of 
"  subjective  after-color  ;"  first,  those  produced  from  the  external  world  or 
natural  light  stimulus  ;  and  second,  those  from  some  internal  stimulus, 
either  in  the  visual  apparatus,  or  in  the  cerebrum  beyond  it.    In  a  previous 
paragraph  it  has  been  more  fully  shown  and  explained  that  every  sensory 
nerve  has  at  Its  peripheral  termination  two  separate  and  distinct  actions 
in  the  receipt  and  the  conversion  of  a  natural  color-stimulus  into  an 
equivalent  nerve  energy ;  first,  a  separation  of  an  amount  of  nerve  force 
equal  to  the  amount  of  an  impinging  natural  stimulus,  from  the  normal 
condition  of  a  resident  nerve-energy  ;  and  second,  a  regain  or  a  return  of 
an  equivalent  amount  of  material  to  that  nerve's  "  energy-equivalent," 
the  moment  the  natural  stimulus  is  taken  away.    This  rule  holds  good  for 
the  entire  length  of  the  sensory  filament  as  well  as  for  the  related  percep- 
tive elements  in  the  cerebral  masses.    Should  there  by  any  means  be 
another  color-stimulus  presented  to  the  primarily  impinged  optic-nerve 
filament  tip,  before  it  has  had  time  to  regain  its  normal  condition,  the  new 
color-stimulus  will  be  reduced  in  its  equivalent  action  by  as  much  as  the 
primary  color-stimulus  has  taken  away,  and  the  result  in  all  cases  will  be 
a  proportionate  difference.    In  other  words,  there  is  a  moment  before  the 
lowered  sensory  nerve  can  be  made  to  properly  obey  its  physiological  law. 
Thus,  suppose  a  red  stimulus  should  be  superimposed  upon  a  white  stimu- 
lus (t.  e.,  a  red  wafer  upon  a  sheet  of  white  paper),  and  that  the  red 
vibrations  should  be  allowed  to  impinge  upon  an  optic-nerve  filament, 
the  natural  stimulus  would  separate  a  nerve-energy  equal  to  itself  from 
the  "  energy-equivalent"  of  the  impinged  optic-nerve  filament,  and  con- 
tinue to  do  so  as  long  as  the  red  stimulus  is  there.    This  is  an  act  of 
continued  separation.    Again,  suppose  that  this  natural  red  color  should 
be  suddenly  removed.    By  this  act  there  would  be  a  natural  stimulus  of 
white  sent  to  the  same  nerve  in  which  the  "  energy-equivalent"  has  been 
lowered  to  an  energy  of  an  amount  equal  to  the  difference  between  the 
nerve's  normal  power  and  the  red  energy.    No  time  has  been  allowed  for 


1885.]     Oliyee,  A  Correlation  Theory  of  Color-perception. 


117 


the  "  energy-equivalent"  to  be  properly  re-formed.  There  would  now  be 
a  dual  action  for  the  impinged  nerve — a  regain  of  the  separated  amount  of 
the  red  energy,  and  a  separation  for  the  impression  of  the  natural  white 
stimulus.  The  result  would  be  a  difference  between  the  white  and  the 
red,  whieh  is  equal,  in  this  case,  to  the  commencing  sensation  of  some 
green.1 

The  same  thing  occurs  when  the  so-called  complement  is  provoked 
upon  some  other  color  surface  than  white.  By  the  sudden  substitution  of 
a  new  color-stimulus,  the  excited  nerve  is  rendered  momentarily  abnormal 
for  the  amount  of  regain  of  the  primarily  seen  stimulus.  If  this  second 
color-stimulus  be  of  greater  value  than  the  amount  of  nerve-energy  left  in 
the  optic-nerve  filament  tip,  the  actual  result  will  be  an  answer  to  a  nerve 
action  equal  to  the  amount  of  energy  left  by  the  primary  stimulus,  which 
of  a  necessity  will  always  be  a  complement  of  the  primarily  seen  color. 
To  explain  :  if  a  natural  red  stimulus  be  superimposed  upon  an  orange 
ground,  theoretically  in  this  particular  instance,  there  would  be  either  one 
of  two  things,  each  dependent  upon  the  separating  power  of  the  second 
color.  First,  a  proper  receipt  of  the  natural  orange  color  (in  which  case 
there  would  not  be  any  complement  at  all,  because  both  the  primary  and 
the  secondary  natural  color-stimulus  would  be  properly  answered),  pro- 
vided that  there  be  sufficient  nerve-energy  material  left  from  the  separat- 
ing action. of  the  primary  red  stimulus  upon  the  energy-equivalent  of  the 
optic-nerve  filament  tip,  to  be  separated  for  transmission  and  perception  of 
the  after  natural  orange  stimulus.  (Here  the  separating  power  of  the 
second  natural  stimulus  (orange)  is  considered  to  be  low.)  Second,  a 
subjective  after-color  of  some  green  upon  the  orange  ground.  The  remain- 
ing energy  would  be  stimulated  to  its  utmost  by  a  natural  color  of  greater 
power  than  it  is  capable  of  receiving.  As  has  been  shown,  the  energy 
that  is  left  is  always  equal  to  the  subjective  complement  of  the  primarily 
seen  color  ;  and,  as  a  consequence,  this  amount  of  energy  is  all  that  can 
be  separated  for  evolution  into  a  completed  perception.  (In  this  latter 
supposition,  the  separating  power  of  the  second  natural  stimulus  (orange) 
is  considered  to  be  high.)  This  latter  is  what  takes  place  when  the 
so-called  complement  is  produced. 

The  belief  that  black  is  the  complement  of  white  is  obviously  incorrect 
because  it  is  based  upon  false  premises.    This  refutation  admits  of  ready 

1  A  good  example  of  a  subjective  after-color  produced  from  a  natural  white  light 
after  prolonged  exposure  of  the  eye  to  a  red  stimulus,  was  once  experienced  hy  the 
writer.  One  dark  night  whilst  he  stood  watching  some  men  at  work  before  the  blast 
furnaces  of  a  large  rolling-mill,  his  attention  was  particularly  attracted  towards 
several  huge  pieces  of  iron  heated  to  .a  cherry-red  color,  that  were  standing  in  a  dark 
corner.  He  gazed  at  the  blocks  for  some  time,  and  upon  turning  to  walk  down  an 
unlighted  street,  noticed  that  the  light  of  a  distant  lamp  appeared  bright  green,  and 
continued  so  until  he  had  nearly  reached  it.  He  then  saw  that  the  lamp  was  covered 
by  a  white  shade. 


118         Oliver,  A  Correlation  Theory  of  Color-perception.  [Jan. 


explanation  ;  for  when  a  certain  number  of  optic  nerve  filament  tips  have 
been  exposed  to  a  definitely  sized  square  of  natural  white  stimulus  upon 
a  larger  area  of  neutral  gray  surface,  there  is  an  answering  nerve  material 
separated  as  a  white  energy  as  long  as  the  tips  are  directed  towards  the 
natural  stimulus.  As  this  white  natural  stimulus  has  been  derived  from 
an  ordinary  impure  natural  colorless  energy,  it  contains  all  of  the  com- 
plements of  that  natural  energy,  and  par  consequence  must  have  impressed 
and  separated  all  of  the  nerve  material  of  the  impinged  tips.  This  sep- 
arated white  nerve  energy  is  transmitted  and  evolved  into  a  perception  of 
white.  Suppose  this  certain  natural  white  stimulus  be  stopped,  and  an- 
other similarly  sized  and  placed  area  of  white  stimulus  be  given  to  the 
impinged  nerve-tips  before  a  formative  action  could  have  taken  place  in 
the  nerve  energy  material ;  all  white  sensation  and  perception  would  be 
at  an  end,  because  the  second  white  natural  stimulus  would  take  away  the 
nerve-energy  material  as  fast  as  it  would  endeavor  to  re-form,  and  would 
not  allow  any  of  it  to  be  separated  for  transmission  and  perception.  This 
condition  would  last  until  the  nerve-energy  material  could  sufficiently 
regain  itself  for  separation.  Consequently  there  would  be  a  space  of  true 
physiological  darkness  equal  in  size  to  the  space  occupied  by  the  prima- 
rily perceived  white  color,  which  was  produced  from  the  first  natural 
white  stimulus  :  an  area  of  "  physiological  nothing"  made  visible  by  sur- 
rounding color,  just  as  a  hole  in  a  board  is  seen  ;  this  area  being  depend- 
ent upon  the  inability  of  the  peripheral  tips  of  a  quantity  of  sensory  nerves 
to  properly  receive  a  series  of  impressing  natural  waves.  This  can  be 
proved  by  the  following  experiment :  Make  of  unglazed  paper  a  card 
containing  three  concentric  rings,  each  ring  of  three  centimetres  width. 
Let  the  middle  one  be  white,  and  the  two  outer  ones  black.  Hang  the 
contrivance  directly  in  front  of  a  nine  centimetres  wide  ring  of  white  paper, 
upon  the  gray  wall  of  a  badly-lighted  room,  in  such  a  manner  as  to  com- 
pletely hide  the  white-ring  card.  Gaze  attentively  at  the  black  and  the 
white  rings  for  at  least  fifteen  seconds.  (Preferably  do  this  when  tired 
and  fatigued,  as  the  result  is  much  more  prompt  and  vivid.)  Whilst  keep- 
ing the  eye  steadily  fixed,  have  the  outer  card  suddenly  removed,  which 
action  will  give  the  impinged  optic  nerve  filament  tips  a  white  stimulus  to 
respond  to.  Instead  of  a  receipt  of  white  there  will  subjectively  appear 
three  concentric  rings,  the  outer  ones  being  white,  and  the  inner  one 
dark.  This  experiment  also  explains  the  fact  that  the  exposing  of  sensi- 
tive peripheral  nerve-tips  to  a  black  surface  does  not  cause  a  separation 
of  sensory  nerve  force  in  the  exposed  terminals ;  thus  conclusively  show- 
ing that  the  popular  idea  of  white  being  the  complement  of  black,  is 
nothing  but  a  crude  and  false  deduction  based  upon  premises  which  con- 
found a  want  of  action  with  action — an  error  that  has  arisen  through  the 
belief  that  a  black  surface  is  an  area  of  natural  sensitizing  material. 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  119 


The  superposition  of  a  natural  white  stimulus  upon  any  other  natural 
color-stimulus  than  white,  practically  causes  an  area  of  momentary  dark- 
ness, because  the  primary  natural  white  stimulus  has  used  all  of  the  resident 
nerve  force,  and  time  has  not  been  allowed  for  the  formation  of  sufficient 
material  to  transform  the  second  natural  stimulus  into  an  equivalent 
nerve-energy.  This  want  of  action  prevents  the  second  natural  color  from 
being  perceived. 

The  series  of  passing  subjective  after-colors  produced  by  excluding  all 
natural  light  rays  from  the  visual  apparatus,  after  it  has  gazed  for  some 
time  upon  pieces  of  white  paper  on  black  surfaces,  held  in  direct  sunlight, 
seem  to  depend  upon  the  fact  that  the  primary  extraneous  white  stimulus 
has  been  of  such  great  intensity  that  even  after  it  has  been  completely 
removed,  it  has  left  an  irritant  action  in  the  exhausted  peripheral  tips, 
which  of  a  necessity  will  separate  for  transmission  and  perception  specific 
nerve-energies  from  the  re-forming  material  as  fast  as  the  material  is  poured 
into  the  tips.  The  fact  that  the  irritant  action  is  ever  decreasing,  with  a 
proportionate  gain  of  the  nerve-energy  material  in  the  tip,  is  the  cause  of 
the  succession  of  subjective  colors.  For  instance,  a  definite  number  of 
optic  nerve-filament  tips  have  been  exposed  for  some  seconds  to  a  white 
stimulus  of  very  great  intensity.  The  extraneous  stimulus  is  suddenly 
stopped.  All  of  the  nerve-energy  material  has  been  extracted  from  the 
exposed  tips.  A  formative  action  immediately  takes  place,  but  this  is 
met  with  an  irritant  in  the  shape  of  the  remains  of  the  intense  white 
natural  stimulus.  A  contest  takes  place  between  the  formative  action  of 
the  nerve-energy  material  and  the  irritant.  The  irritant  separates  the 
nerve  material  as  fast  as  formed.  The  gradual  loss  of  irritating  action  is 
evinced  in  the  passing  changes  of  perceived  color.  The  victory  is  given 
to  the  nerve-energy  material,  because  the  material  has  had  a  source  of 
constant  renewal,  whereas  the  irritant  action  has  died  from  the  want  of 
fresh  supply  of  natural  stimulus.  It  may  be  that  this  result  is  indirectly 
augmented  by  a  devitalizing  action  of  the  intense  white  stimulus  upon  the 
organic  constituents  of  the  tip  itself,  which  physicial  alteration  prevents 
proper  physiological  working  ;  the  various  color  changes  being  dependent 
in  some  measure  upon  the  character  of  the  reparative  action  taking  place 
in  the  recipient  tissues.  This  supposition  is  borne  out  by  the  so-called 
blending  effect  of  direct  sunlight  upon  the  human  retina. 

If,  instead  of  excluding  the  visual  apparatus  from  all  natural  light  after 
it  has  gazed  for  some  time  upon  the  pieces  of  white  paper  on  the  black 
surfaces  held  in  the  bright  sunlight,  it  should  be  immediately  re-exposed' 
to  the  same  slips  of  white  paper  to  which  the  first  exposure  was  made, 
there  will  subjectively  appear  the  same  character  of  passing  colors  as  were 
made  subjectively  visible  in  the  preceding  experiment,  except  that  now 
they  will  progress  in  a  reverse  order.    The  reason  for  this  can  be  readily 


120         Oliver,  A  Correlation  Theory  of  Color-perception.  [Jan. 


given.  During  the  time  that  the  reimpressed  exhausted  tip  is  gradually 
gaining  sufficient  nerve-energy  to  transmit  the  second  natural  white  stimu- 
lus, there  is  a  corresponding  separating  process  continually  taking  place, 
dependent  upon  the  great  intensity  of  the  second  natural  white  stimulus. 
These  separated  amounts  of  nerve-energy  are  forwarded  to  the  perceptive 
centres  where  they  are  recognized.  This  continues  in  a  definite  order  of 
gain,  until  at  last  the  second  natural  white  stimulus  is  able  to  be  properly 
received  as  an  equivalent  nerve-energy,  which  is  transmitted  and  per- 
ceived as  "  white." 

Both  of  these  experiments  first  show  the  so-called  "  objective  comple- 
ment" of  the  primarily  exposed  natural  color,  followed  by  visible  expres- 
sions of  regain  of  nerve-energy  material  under  different  circumstances. 

The  subjective  after-colors  seen  by  an  eye  exposed  to  a  feeble  stimulus 
of  natural  color  when  its  fellow  is  made  to  receive  a  strong  stimulus  of 
some  other  natural  color,  must  necessarily  be  dependent  upon  a  transfor- 
mation of  a  "remaining  energy"  of  one  of  the  primarily  used  perceptive 
color-cells  belonging  to  the  strongly  impressed  visual  apparatus,  to  an 
equivalently  placed  perceptive  color-cell  belonging  to  the  weakly  impressed 
visual  apparatus ;  the  primary  weak  excitation  of  the  secondarily  and  in- 
ternally impinged  perceptive  color-cell  causing  a  primary  separation  of  but 
a  minimum  amount  of  nerve-force  material  to  be  regenerated  for  recogni- 
tion  and  projection  of  the  internal  stimulus.  It  is  nothing  but  the  action 
of  the  "  remaining  energy"  of  a  lowered  though  highly  excited  perceptive 
color-cell  belonging  to  one  channel  to  the  external  world  upon  another 
similar  and  responsive  perceptive  color-cell  with  a  "  remaining  energy," 
belonging  to  a  like  channel  to  the  outer  world.  As  the  most  probable 
cause  for  this  character  of  response  must  have  been  dependent  upon  a  con- 
nection of  the  perceptive  cells  belonging  to  the  two  sensory  apparatuses, 
although,  from  the  very  nature  of  things,  all  normal  human  cerebral  action 
must  ordinarily  be  dual  in  its  physicial  nature  and  physiological  action, 
yet  it  is  the  most  reasonable  to  suppose  that  at  the  time  of  the  double 
action  of  the  visual  apparatuses,  the  perceptive  cells  of  each  were  physi- 
cally and  physiologically  thrown  into  connection  with  each  other.  How 
this  may  have  been  done,  whether  by  continuity  of  material  tissue,  chemico- 
vitally  or  by  some  unknown  agent,  it  is  impossible  to  say.  That  there  is 
an  organic  or  life  connection  at  such  times  is  known  by  the  blending  of 
the  finite  results  ;  but  even  if  continuity  of  molecule  could  be  traced  during 
such  action,  the  fact  of  a  new  perceptive  color-cell  being  attacked  by  a 
definite  stimulus,  which  sets  free  a  specific  energy,  does  not,  destroy  the 
weight  of  the  argument  that  might  be  forwarded  for  not  considering  it  a 
"  subjective  after-color"  in  the  same  light  as  the  author,  because  the  inter- 
nally impinged  cell  has  been  lowered  to  a  "remaining  nerve-energy"  by 
its  weak  primary  action.    Thus,  in  one  of  the  interesting  and  ingenious 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  121 


experiments  by  Gorham,1  where  a  subjective  green  is  made  to  appear  to  a 
visual  apparatus  which  has  been  exposed  to  a  weak  natural  white  stimulus, 
whilst  the  opposite  visual  apparatus  has  been  given  a  strong  stimulus  of 
natural  red  color,  the  answer  cannot  be  arrived  at  in  any  other  way.  The 
fact  of  white  being  the  weak  primary  separation  in  this  experiment  appears 
as  a  vulnerable  point  in  the  argument ;  but  the  force  of  this  is  contro- 
verted by  the  extreme  weakness  of  the  intensity  of  the  action  from  the 
natural  white  color,  in  contradistinction  to  the  great  strength  of  the  oppo- 
site internal  stimulus,  the  question  being  one  of  a  difference  in  intensity. 

The  same  character  of  reasoning  that  has  been  offered  in  explanation 
of  the  preceding  class  of  experiments  may  be  adduced  in  favor  of  the  so- 
called  "  simultaneous  contrast  colors,"  in  showing  that  either  the  action 
of  simultaneously  powerful  and  feeble  intensities  of  natural  color  stimuli 
or  of  a  prolonged  exposure  of  a  strong  and  a  weak  natural  color  impres- 
sion upon  a  series  of  contiguous  peripheral  nerve  terminals  of  the  same 
visual  apparatus  can  readily  provoke  an  internal  irritant  action  in  the 
strongly  excited  perceptive  color-cell,  which  will,  in  its  turn,  cast  the 
entire  brunt  of  its  remaining  nerve-force  upon  its  feebly  excited  neighbor, 
and  thus  rouse  the  now  secondarily  impinged  cell  into  a  corresponding 
action.  This  is  found  to  be  most  likely  the  case,  when  it  is  remem- 
bered that  these  cells  have  probably  through  their  simultaneous  primary 
action  been  physically  and  physiologically  thrown  into  connection  with 
each  other.  It  will  not  be  necessary  to  give  the  many  variations  of  this 
variety.  The  recital  of  two  experiments  will  suffice  for  all.  First,  when 
a  small  square  of  weak  red  stimulus  placed  upon  a  large  area  of  intense 
natural  red  appears  greenish,  the  supposition  as  to  causation  belongs  to 
the  first  rule — "  simultaneously  powerful  and  feeble  intensities."  An 
experiment  illustrating  the  second  rule,  i.  <?.,  prolonged  exposure  of  a 
strong  and  a  weak  natural  stimulus  may  be  cited  by  having  a  small  strip 
of  dull-grayish  paper  placed  in  juxtaposition  to  a  similarly  sized  strip  of  a 
bright-green  paper,  in  which  case,  after  some  seconds'  exposure,  the 
border  of  the  dull-gray  strip  next  to  the  bright-green  will  have  a  reddish 
cast.2 

The  so-called  "  multiple  complements,"  or  rather  "  alternating  subjec- 
tive after-colors,"  as,  for  instance,  in  the  following  example,  where  alter- 
nating subjective  perceptions  of  green  and  of  red  have  been  aroused  by 

1  "  On  the  Blending  of  Colors  by  the  Sole  Agency  of  the  Sensorium."  By  John  Gor- 
ham, M.R.C.S.,  Tunbridge;  Brain  :  A  Journal  of  Neurology,  vol.  iv.  p.  467.  As  early 
as  1808  Sir  David  Brewster  obtained  similar  results  in  an  almost  identical  way.  (  Vide, 
p.  257  of  the  first  American  edition  of  A  Treatise  on  Optics.  By  Sir  David  Brewster, 
LL.D.,  F.R.S.L.  &  E.,  etc.,  Philadelphia,  1845. 

2  These  experiments  might  be  multiplied  almost  indefinitely  in  different  ways,  with 
varying  though  corresponding  results.  Buffon,  Schaeffer,  Westfield,  Chevreul,  Brew- 
ster, etc.,  have  all  given  a  great  number  of  interesting  modifications  of  this  variety  of 
subjectivism. 


122         Oliver,  A  Correlation  Theory  of  Color-perception.  [Jan. 


sensory  and  perceptive  materials  set  into  activity  through  the  action  of 
either  a  recognized  objective  natural  green  color  or  a  subjective  green  in 
producing  a  red  subjective  after-color,  are  most  probably  dependent  upon 
momentary  alternating  regains  and  discharges  of  sufficient  energy  mate- 
rial to  perceive  color  energies  equal  to,  first,  the  primary  energy  and  then 
its  subjective  after-color,  after  having  had  perceived  the  subjective  after- 
color.  It  is  a  modification  of  the  same  old  battle  though  now  transferred 
to  the  perceptive  cells  ;  the  changes  in  the  passing  results  being  dependent 
upon  some  peculiar  condition  under  which  the  new  variety  of  weapon  is 
wielded. 

So  far  the  first  division  has  been  discussed.  Endeavors  will  now  be 
made  to  explain  the  causes  of  the  different  actions  coming  under  the 
second  head,  where  the  visual  apparatus  has  either  an  irritant  taking  birth 
within  itself  or  a  cerebral  stimulus  to  respond  to.  In  the  first  instance, 
there  cannot  be  any  doubt  but  that  it  is  possible  for  the  subjective  after- 
colors  to  be  provoked  by  an  irritant  affecting  any  part  of  the  visual  appa- 
ratus. Suppose  the  following  case :  sudden  squeezing  of  the  sensory 
elements  of  the  transmitting  parts  of  the  optic  nerve,  from  some  momen- 
tary blood-pressure  increase,  with  a  production  of  the  perception  of  sub- 
jective color.  This  symptom  means  that  a  traumatic  stimulus  has  caused 
a  separation  of  a  definite  amount  of  nerve-energy,  which  specific  quantity 
is  transmitted  and  perceived  as  though  it  had  been  set  into  motion  by  a 
color-stimulus  of  external  origin.  If  this  traumatic  stimulus  should  be 
continued  for  a  few  moments  longer,  then  suddenly  dropped,  and  the  visual 
apparatus  subjected  to  another  act  of  traumatism,  the  second  subjective 
visual  result  would  be  diminished  by  as  much  power  as  had  been  extracted 
by  the  first  act  of  traumatism,  and  the  answer  would  be  equal  to  the 
amount  of  difference.  If  the  primary  irritating  force  should  transmit  all 
of  the  resident  nerve-energy  there  would  not  be  any  perception  caused  by 
the  second  force.  These  rules  hold  good  for  any  part  of  the  visual  appa- 
ratus, no  matter  whether  the  exciting  stimuli  originate  in  the  ocular  retina, 
the  conducting  nerves,  or  in  the  cerebral  sheet.  Under  this  category 
come  the  answers  to  the  questions  suggested  by  the  production  of  subjec- 
tive colors  when  the  visual  apparatus  is  not  exposed  to  natural  color- 
stimulus.  For  easy  study  there  have  been  two  subdivisions  made  :  First, 
the  production  of  the  so-called  complements  when  the  organ  of  sight  is 
in  complete  darkness;  and  second,  the  production  of  the, so-called  com- 
plements when  the  organ  of  sight  is  directed  against  a  black  surface. 
Practically,  these  two  divisions  are  the  same.  The  following  example 
illustrates  a  cause  coming  under  the  first  subdivision.  A  man  walking  in 
the  dark  suddenly  strikes  his  eye  against  a  heavy  blunt  obstacle.  He  has 
an  immediate  subjective  perception  of  red  flashes  of  light.  A  moment 
later  his  organ  of  sight  encounters  with  much  greater  force  a  second 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  123 


obstacle,  and  there  arises  a  perception  of  a  subjective  green.  Here  there 
is  a  blow  upon  the  outer  tunics,  followed  by  a  stronger  second  one,  each 
causing  a  contre  coup  upon  the  sensory  elements  of  an  equivalent  nerve- 
energy  power  ;  the  second  blow  or  stimulus  having  arrived  before  a  forma- 
tive action  for  the  amount  of  separated  nerve-energy  caused  by  the  pri- 
mary act  has  taken  place.1  If  white  light  had  been  the  primary  subjective 
color  there  would  not  have  been  any  subjective  after-color. 

Where  subjective  colors  are  produced  by  changes  in  cerebral  structure, 
or  in  actions  taking  their  origin  within  the  limits  of  perceptive  material, 
the  same  reason  for  cause  and  effect  as  expressed  in  the  paragraph  upon 
subjective  color-changes  originating  from  excitants  taking  their  birth 
within  the  visual  apparatus,  must  be  accepted  as  truisms,  although  it 
should  be  strictly  understood  that  when,  in  its  studies,  the  human  men- 
tality approaches  the  domain  of  the  cerebral  forces,  and  demands  answers 
as  to  the  why  and  the  wherefore  of  the  physical  changes  and  the  physio- 
logical actions  occurring  within  itself,  it  assumes  a  position  bordering 
almost  upon  the  search  of  the  infinite.  It  must  be  agreed  that  there  are 
two  distinct  changes  taking  place  in  the  conversion  of  a  sensation  into  a 
properly  recognized  perception.  First,  an  action  upon  the  lower  mentality 
by  the  received  sensory  result,  which  has  been  spread  upon  the  cerebral 
retina,  causing  a  physical  change  in  the  contiguous  cerebral  material,  with 
a  production  of  the  primary  form  of  a  perception.  Second,  a  conversion 
of  this  automatic  perception  into  a  higher  form  through  the  action  of  a 
conveyed  and  everchanging  quality  of  perception  upon  a  certain  amount 
of  physical  material  resident  near  or  in  the  centres  of  intelligence.  These 
two  actions  constitute  the  direct  order  of  the  complete  evolution  of  a  color- 
perception  as  well  as  the  last  physiological  rule  of  consummated  vision. 
If  it  thus  be  accepted  that  the  evolved  perception  of  a  completely  sensi- 
tized color-energy  passes  through  the  same  character  of  stations,  and  is 
subject  to  the  same  laws,  although  now  of  a  higher  grade  of  nerve  material 
and  cell-action,  as  it  did  whilst  pursuing  its  course  inwards  as  a  sensation, 
and  that  similar  acts  of  separation  and  re-formation  as  were  attributed  to 
the  production  of  the  completed  form  of  color-sensation  in  the  visual  appa- 
ratus occur  in  the  related  perceptive  elements  of  the  cerebrum,  it  must 
be  admitted  that  momentary  alterations  and  transitory  physical  changes 
in  these  perceptive  structures  may  happen  in  such  a  way  as  not  only  to 
produce  subjective  color-images,  but  actually  to  make  the  ego  doubt  the 
subjective  quality.  For  instance,  suppose  the  production  of  a  subjective 
after-color  upon  a  black  surface,  after  the  perception  of  a  natural  color 
stimulus.    Here  the  second  stimulation  upon  the  perceptive  color  cells 

1  This  example  might  be  multiplied  in  many  ways,  and  the  stimulus  made  to  origi- 
nate in  any  part  of  the  visual  apparatus,  but  for  proper  explanation ■,  this  selection  is 
thought  to  be  sufficient. 


124         Oliver,  A  Correlation  Theory  of  Color-perception.  [Jan. 


must  be  of  central  origin,1  because  the  moment  the  primary  natural  force 
is  removed  there  is  absolutely  nothing  external  left  to  reexcite  the  exposed 
peripheral  terminals  of  the  optic  nerve.  To  explain  :  Suppose  that  a  small 
square  of  red  color  be  placed  upon  a  dead-black  surface,  and  a  visual  appa- 
ratus be  allowed  to  fix  upon  it  for  several  moments  by  the  aid  of  a  good 
light.  Without  moving  the  organ  of  vision  from  the  point  of  fixing,  have 
the  red  square  suddenly  taken  away,  and  the  light  decreased  to  almost  a 
minimum  intensity,  and  there  can  be  made  to  subjectively  appear  a  green 
color  upon  the  portion  of  the  dead-black  surface  previously  occupied  by 
the  red  stimulus.  In  this  experiment  a  portion  of  the  energy  material  of 
the  impinged  optic  nerve  filament  tip  has  been  separated,  evolved,  and 
perceived  as  red  ;  whilst  a  remaining  nerve-energy  material  sufficient  for 
the  perception  of  a  subjective  complement  of  the  transmitted  and  perceived 
primary  nerve-energy  has  been  left  untouched.  The  acting  sensory  fila- 
ment has  been  lowered  to  a  transmitting  power  equal  to  the  amount  of 
nerve-energy  left  in  its  tip  ;  whilst  the  internal  termination  of  the  filament 
upon  the  cerebral  retina  has  been  reduced  in  its  power  to  an  amount  equal 
to  the  difference  between  its  normal  equivalent  and  the  quotient  of  value 
of  the  perceived  primary  nerve-energy.  The  sudden  removal  of  the  natu- 
ral stimulus,  with  the  substitution  of  an  area  that  is  incapable  of  throwing 
out  any  vibrations  of  natural  color,  causes  an  immediate  cessation  of  sepa- 
ration and  transmission  of  the  nerve-energy  of  the  primary  stimulus,  with 
an  attempt  of  formative  action  commencing  in  the  peripheral  tip  of  the 
abnormalized  optic-nerve  filament,  and  passing  inwards  throughout  the 
whole  connected  extent  of  the  sensory  nerve.  Before  the  restitution  of 
the  nerve-force  material  has  reached  the  central  terminus  of  the  tip's  fila- 
ment, there  has  arisen  an  excitant  in  the  cerebral  cortex,  either  through 
will-power  or  emotion,  which  excitant  has  acted  upon  the  acting  central 
terminus  of  the  optic-nerve  filament,  and  caused  a  separation  from  the 
nerve-energy  material  remaining  in  the  terminus  ;  thus  producing  a  per- 
ception of  a  subjective  complement  of  the  primarily  perceived  color.  For 
obvious  reasons,  should  the  experiment  have  been  tried  with  a  square  of 
natural  white  color,  there  would  not  have  arisen  any  true  "  subjective 
after-color"  at  all.  If  the  under  larger  surface  had  been  gray  instead  of 
black,  there  would  have  been  a  visible  area  of  subjective  darkness,  equal 
in  size  to  the  removed  white  square,  because  in  reality  in  the  above  ex- 
periment of  a  white  color  upon  a  black  surface  there  is  as  a  result,  in 
addition  to  the  great  amount  of  unused  sensory  nerve  terminals,  a  small 
area  of  exhausted  tips,  which  area  is  rendered  invisible  by  reason  of  the 
non-employment  of  the  surrounding  nerve-tips  ;  whilst  in  the  latter  experi- 
ment upon  a  gray  ground  there  is  a  sufficient  natural  sensitizing  material 
affecting  the  surrounding  optic-nerve  fibre  tips  to  cause  the  area  of  non- 

1  This  excludes  internal  forces  that  may  arise  in  the  sensory  portions  of  the  visual 
apparatus. 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception. 


125 


action  to  be  perceptible.  (Had  the  primary  natural  white  stimulus  been 
very  strong,  there  probably  might  have  been  a  series  of  passing  subjective 
color  changes.) 

The  same  line  of  reasoning  might  be  used  if  the  primary  stimulus  had 
been  of  internal  origin  ;  the  only  difference  being  that  in  this  case  there 
would  not  have  been  any  external  stimulus  whatever.  This  might  be 
illustrated  by  placing  the  organ  of  sight  in  the  dark,  and  causing  a  second 
cerebral  stimulus  to  act  upon  a  perceptive  color-cell  which  had  been  lowered 
by  some  previous  cerebral  act. 

All  of  these  observations  upon  "  subjective  after-color,"  whether  pri- 
marily produced  from  extraneous  or  internal  stimuli,  have  dealt  with  the 
perceptive  cells  belonging  to  the  most  sensitive  regions  of  either  the  ocular 
retina  or  the  cerebral  retina.1  Experiments  as  to  the  possibility  of  the  pro- 
duction of  subjective  after-colors  through  the  peripherally  placed  cells2  would 
be  of  value;  although  from  the  arguments  brought  forward  in  this  theory  it 
is  certain  that  if  sufficient  intensities  and  large  enough  areas  could  be  given 
to  two  complementary  natural  colors,  or  that  two  internal  forces  equivalent 
to  those  from  the  two  natural  complements  could  be  aroused,  so  that  their 
actions  would  be  separately  perceived  by  the  eccentrically  placed  percep- 
tive cell  (as  we  know  is  possible),  the  subjective  after-color  of  either  of 
the  natural  colors  or  of  the  internal  stimuli,  could  be  provoked  from  the 
remaining  energy  of  the  primarily  excited  cell. 

The  other  varieties  of  subjective  after-colors  are  dependent  upon  modi- 
fications of  the  just  described  exciting  agencies  and  conditions  of  physical 
material.  It  is  for  these  reasons  that  no  endeavors  for  their  explanation 
have  been  given. 

Fourth.  Color-perception  as  caused  by  the  action  of  internal  stimuli 
upon  nerve-energies  which  have  not  been  lowered  by  any  preceding  act. 
Subjective  Color.  Under  this  heading  come  all  those  visible  expressions 
of  actions  upon  unused  perceptive  color-cells,  through  internal  force  set 
into  activity  by  internal  agencies.  It  differs  from  the  preceding  head  in 
the  fact  that  the  color-perceiving  cell  has  not  been  lowered  in  its  individual 
forces  by  any  previous  act  upon  its  nerve  energy  material.  Here  there 
is  not  a  "  remaining  energy"  ;  the  energy  is  in  its  entirety,  and  ready  to 
give  subjective  visible  expression  to  any  color  that  it  has  once  known  ob- 
jectively. If  the  material  of  the  nerve  energy  should  be  of  the  finest  type, 
and  its  visible  white  of  the  purest  variety,  then  the  more  individual  color 

1  As  this  theory  presumes  a  central  as  well  as  a  peripheral  expansion  of  the  visual 
apparatus  analogous  to  the  roots  and  branches  of  a  tree,  it  does  not  seem  unjustifiable 
to  speak  of  the  most  sensitive  region  of  the  cerebral  retina,  when  it  is  remembered  that 
the  individual  components  of  the  two  retina?  bear  equivalent  physical  a  nd  physiological 
relations  with  each  other. 

2  By  "peripherally  placed  cells"  is  meant  the  probable  position  upon  the  cerebral 
cortex  of  those  perceptive  color-cells  which  are  the  internal  representatives  of  the  optic- 
nerve  filaments  of  the  circummacular  regions  of  the  ocular  retina. 


126         Oliver,  A  Correlation  Theory  of  Color-perception.  [Jan. 


gradations  it  has  under  its  jurisdiction,  and  the  more  subjective  colors  can 
be  separated  from  it  for  perception.  This  presumes  that  there  is  no  con- 
genital or  hereditary  mental  power,  and  that  all  mental  force  must  have 
been  derived  from  the  external  world.  (The  true  reason  of  "Hereditary 
Genius"  is,  that  one  brain  may  have  a  more  highly  developed  material 
structure,  or  a  stronger  physical  substance  devoted  to  certain  mentalities 
than  another  brain,  and  that  the  first  organ  by  an  equivalent  amount  of 
physiological  action  as  the  second,  may  be  productive  of  better  work  than 
its  less  fortunate  companion  ;  marking  the  possessor  of  the  better  built 
machinery  as  a  remarkable  "  color-seer,"  or  a  fine  "  sound-hearer,"  etc. 
If  the  individual  who  possesses  this  better  substance  should  persist  in  an 
avocation  fitted  for  the  constant  use  of  such  structures,  he  will  cause  rapid 
increase  of  physical  material  in  the  parts,  and  thus  through  extra  powers 
of  receipt  and  response  be  brought  into  eminence.)  This  is  the  true 
foundation  of  the  superiority  of  one  perceptive  color-cell  material  over  that 
of  another  similarly  placed  and  used  cell.  This  is  the  reason  that  there 
must  be  different  grades  of  subjective  colors  dependent  upon  the  strength 
of  variously  placed  nerve  energies  and  provoked  internal  stimuli,  just  as 
there  were  differences  in  objective  colors  dependent  upon  the  value  of  the 
receiving  fibre,  as  well  as  the  amount  and  character  of  natural  stimuli. 
Internal  stimuli  acting  upon  responsive  perceptive  material  may  be  assumed 
in  many  ways,  such  as  through  sudden  vascular  changes,  or  by  momentary 
pressures  upon  sensory  tissue.  That  this  is  actually  so,  is  fairly  presum- 
able from  the  everyday  experiences  of  the  victims  of  the  visual  types  of 
either  "conscious  centric  (or  subjective)  pseudopia,"  or  "unconscious 
centric  (or  subjective)  pseudopia,"  1  or  of  "  Hallucinations,"  as  Hammond2 
prefers  to,  call  them.  Yet  as  it  is  neither  in  the  province  nor  in  the  scope 
of  this  paper,  to  enter  more  fully  into  this  part  of  the  subject  than  will  be 
sufficient  for  explanation  of  the  causes  of  a  few  of  the  prominent  varieties 
of  subjective  color,  all  others  will  be  set  aside,  so  as  to  allow  deductions  to 
be  drawn  from  the  chosen  examples.  The  varieties  will  be  primarily 
divided  into  two  groups — the  physiological  and  the  pathological.  The 
former  will  be  treated  of  here,  whilst  the  latter  will  be  reserved  for  the 
third  portion  of  the  paper,  in  order  that  the  various  causative  stimuli  of 
abnormal  nature  may  be  placed  in  their  proper  and  respective  groupings.3 

1  These  terms  first  made  use  of  by  Dr.  Ed.  H.  Clarke,  in  an  excellent,  though  un- 
finished essay  upon  "Visions:  a  Study  of  False  Sight  (Pseudopia)."  Boston,  1878, 
8vo.,  pp.  315. 

2  Divided  into  two  kinds,  "  recognized"  and  "  delusive."  "  Diseases  of  the  Nervous 
System."    By  Wm.  A.  Hammond,  M.D. 

3  Strictly  speaking,  hallucinations  occurring  when  the  visual  apparatus  is  impressed 
by  natural  color,  as  in  ordinary  daylight,  should  be  considered  as  having  been  caused 
by  actions  upon  remaining  nerve-energies  in  previously  impinged  perceptive  color- 
cells. 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  127 


Physiologically,  it  does  not  matter  in  what  internal  situation  the  abnor- 
mal stimulus  originates.  If  there  should  be  a  momentary  attack  upon  any 
perceptive  color-cell,  there  would  be  an  immediately  perceived  action.  For 
instance,  the  sudden  appearance  and  disappearance  of  phosphenes  from  some 
internal  momentary  blow  upon  the  region  of  perceptive  color-cells,  when  the 
visual  apparatus  is  either  in  a  dark  room,  or  when  it  is  directed  against  a 
black  surface.1  Here  there  is  a  physiological  action  of  a  properly  charged 
color-cell,  from  an  abnormal  process  of  stimulation.  The  physiological 
action  of  the  cell  is  perfect,  and  the  amount  of  action  is  dependent  upon  the 
force  of  the  internal  stimulus. 

The  same  explanation  holds  good  should  an  experiment  be  made  by 
which  a  subjective  color  should  be  projected  from  an  unused  sensory  fila- 
ment upon  a  black  surface,  or  into  a  dark  space,  during  the  time  that  its 
contiguous  filaments  are  being  exposed  to  strong  intensities  of  natural 
color  for  some  length  of  time  ;  the  only  difference  being  that  here  there  is  a 
change  in  the  kind  of  natural  cause,  and  the  character  of  its  invasion. 
At  first  sight,  it  may  appear  as  if  it  should  in  reality  have  been  placed 
under  the  preceding  head  "  subjective  after  color,"  but  upon  making  sepa- 
ration of  the  reasons  for  the  various  manifestations,  the  proper  situation 
will  be  found  to  have  been  chosen.  Here  there  is  a  strong  internal 
stimulus  from  the  perceptive  cell  of  the  strongly  impressed  sensory  fila- 
ment acting  upon  the  unused  perceptive  cell  of  the  unimpinged  second 
sensory  filament,  giving  a  definite  and  equivalent  response  in  the  percep- 
tive cell  of  the  second  sensory  filament.  This  does  not  in  any  way  mean 
that  there  is  an  action  of  a  "  remaining  energy"  of  the  perceptive  cell 
which  has  been  impinged  by  the  internal  force,  but  that  the  internal 
stimulus  from  the  primarily  lowered  perceptive  cell  is  of  a  complementary 
type. 

Reasoning  from  these  lines  of  argument,  it  can  be  assumed  as  a  certainty 
that  the  latter  experiment  might  have  been  so  modified  as  to  cause  sub- 
jective colors  to  appear  to  an  unexposed  second  eye,  because  even  here 
there  is  a  definite  amount,  and  a  definable  source  of  stimulus  to  attack  the 
working-  material  of  the  unused  organ.2 

*  The  origin  of  this  force  may  have  been  external,  as  from  a  blow  upon  the  vault  01 
the  cranium. 

2  At  this  point,  "  physiological  research"  is  ended.  In  the  concluding  paper,  which 
will  appear  in  the  April  number  of  this  journal,  "pathological  data  in  support"  and  a 
"  risumi"  will  be  given. 


128  Kemper,  Lodgment  of  a  Breech-pin  in  the  Brain.  [Jan. 


Article  IX. 

A  Case  of  Lodgment  of  a  Breech-Pin  in  the  Brain  ;  Removal  on  the 
Second  Day  :  Recovery.  By  G.  W.  H.  Kemper,  M.D.,  of  Muncie, 
Indiana. 

On  the  19th  day  of  April,  1884,  Emerson  McC,  a  robust  farmer  boy, 
aged  18  years,  received  a  compound  fracture  of  the  frontal  bone,  imme- 
diately above  the  right  frontal  sinus,  by  a  bursting  gun.  About  noon,  as 
ascertained  from  persons  who  heard  the  report  of  the  gun,  while  the 
weapon  was  in  position  before  his  face,  he  fired  at  a  squirrel.  Four  hours 
later  he  made  his  way,  unaided,  to  his  father's  home.  An  investigation 
revealed  the  facts  that  the  accident  had  occurred  one-half  a  mile  from  the 
home,  the  gun  had  been  broken  into  numerous  pieces,  and  he  had  lain  on 
the  ground  for  a  considerable  length  of  time  in  an  insensible  condition. 
The  hemorrhage  had  been  moderate  in  quantity,  and  about  half  a  tea- 
spoonful  of  brain  substance  was  found  upon  the  leaves. 

Dr.  D.  O.  Munsey,  of  New  Corner,  the  family  physician,  was  sum- 
moned, and  arrived  about  six  o'clock.  He  found  the  patient  suffering  but 
little  pain,  and  his  mind  was  clear.  Cold  water  dressings  were  applied — 
a  critical  examination  of  the  wound  being  postponed  for  a  consultation. 

At  9  A.M.  of  the  20th — about  twenty-one  hours  after  the  receipt  of  the 
injury — I  saw  the  patient.  The  temperature  was  104f  °  ;  pulse  64.  He 
felt  but  slight  pain,  and  the  mental  faculties  were  unclouded.  He  had 
slept  well  during  the  night.  The  tissues  around  the  right  eye  were  con- 
siderably swollen,  and  blackened  with  powder  stains.  A  partially  curved 
wound,  about  one  and  a  half  inches  long,  was  located  vertically  above  the 
right  eyebrow.  Raising  the  valve-like  flap  of  skin,  1  found  quite  an  aper- 
ture through  the  two  plates  of  the  frontal  bone.  Passing  my  finger 
through  this  and  into  the  brain  to  search  for  any  pieces  of  bone  that 
might  be  detached,  at  a  distance  of  half  an  inch  beyond  the  internal 
plate,  I  felt  a  serrated  object,  and,  guided  by  my  finger,  I  introduced  a 
dressing  forceps,  and  seized  and  withdrew  it — the  breech-pin  of  a  gun, 

I  presume  the  characteristic  shape  of  the  wound  of  the  skin  and  soft 
tissues  was  made  by  the  iron  striking  with  its  long  diameter.  After  en- 
tering the  cranial  cavity  the  base  of  the  pin  advanced,  and  left  the  small 
end  towards  the  point  of  entrance,  and  this  was  the  point  I  first  touched. 
Some  five  or  six  small  pieces  of  detached  bone  were  removed  at  this  time, 
and  two  or  three  more,  with  a  piece  of  his  felt  hat,  worn  at  the  time  of  the 
accident,  appeared  at  the  opening  of  the  wound,  several  days  later,  and 
were  removed  by  Dr.  Munsey. 

During  all  the  time  of  my  manipulations  the  patient  made  but  slight 
complaint  of  pain — having  refused  to  inhale  an  anaesthetic.  The  shape 
and  natural  size  of  the  iron  is  shown  in  the  accompanying  cut  (Fig.  1). 
The  iron  weighed  617  grains;  length,  lj  inches. 


1885.        Kemper,  Lodgment  of  a  Breech-pin  in  the  Brain.  129 


Water  dressings  were  applied,  and  all  Fig- 
facilities  afforded  for  the  ready  escape  of 
pus.    No  opiates  were  administered  at  any 
period.    At  the  close  of  the  dressing  the 
pulse  was  72. 

From  this  date  forward  he  was  under  the 
care  of  Dr.  Munsey,  who  has  kindly  fur- 
nished the  following  memoranda  of  the 
case : — 

April  21.  9  A.M.  pulse  68;  resp.  18;  temp.  100.7°. 

22d.  10  A.M.  pulse  72;  resp.  16,  and  irregular;  temp.  100°.  Slight 
delirium  last  night. 

23d.  Pulse  64;  resp.  12;  temp.  100°.  The  flow  of  pus  became  ob- 
structed in  the  afternoon,  and  early  in  the  evening  he  had  a  convulsion. 

2Uh.  Pulse  64;  resp.  14;  temp.  99.5°. 

26th.  Pulse  64;  resp.  14;  temp.  99°. 

28th.  Pulse  62;  resp.  12;  temp.  98.5°. 

May  2d.  Pulse  66;  resp.  14;  temp.  98.5°. 

He  made  a  rapid  and  excellent  recovery,  and  was  dismissed  by  Dr. 
Munsey  on  May  4th,  at  which  time  the  pulse  was  72;  resp.  16;  and 
temp.  98.5°. 

The  patient  called  upon  me,  at  my  office,  on  the  13th  day  of  Sep- 
tember, nearly  five  months  after  the  occurrence  of  the  accident.  A 
picture,  taken  at  this  visit  (Fig.  2),  gives  a  good  illustration  of  the  appear- 


ing. 2. 


No.  CLXXVII.—Jan.  1885.  9 


130 


Hamilton,  Introspective  Insanity. 


[Jan. 


ance  of  the  patient.  The  cicatrix  showed  no  tenderness  on  pressure.  The 
pulsations  beneath  it  can  be  seen  and  felt.  The  vision  of  both  eyes 
is  perfect.  A  number  of  powder  stains  remain  beneath  and  above  the 
left  eye.  During  the  summer  he  has  felt  the  heat"  so  that  he  could 
not  engage  at  active  manual  labor  in  the  rays  of  the  sun  ;  otherwise  he 
considers  himself  as  well  as  he  was  before  the  accident.  His  memory  is 
not  affected. 

Remarks  It  will  be  observed  that  no  untoward  symptoms  were  devel- 
oped in  this  case  until  the  evening  of  the  23d,  when  a  convulsion  ensued 
because  of  pent-up  pus,  and  no  further  trouble  followed  after  the  removal 
of  the  cause.  In  the  very  interesting  report  in  the  American  Journal 
of  the  Medical  Sciences  (July,  1882,  p.  45),  of  a  somewhat  similar 
case,  by  Dr.  Noyes,  of  New  York,  he  calls  attention  to  the  necessity  of 
free  drainage,  and  says  : — 

"It  is  not  pretended  that  the  most  perfect  provision  for  outflow  of  fluid  will 
prevent  an  abscess  from  extending  farther  into  the  brain,  and  thus  becoming 
fatal.  But  we  certainly  have  to  strive  to  remove  all  obstacles  which  tend  to 
favor  its  extension.  In  the  famous  Harlow-Bigelow  tamping-iron  case,  Dr.  Har- 
low, in  a  private  letter  to  me,  says  that  it  was  due  in  great  measure  to  the  free 
outlets  through  the  skull  below  and  above  that  the  man  Gage  owed  his  life." 


Article  X. 

Introspective  Insanity5  [Folie  du  doute ;  Grubelsucht).  By  Allan 
McLane  Hamilton,  M.D.,  one  of  the  Consulting  Physicians  to  the  New 
York  City  Insane  Asylum,  etc. 

Among  those  vague  conditions  of  mental  weakness  in  which  there  is 
slight  derangement  of  the  intellectual  powers,  yet  a  decidedly  marked 
enfeeblement  of  the  will,  and  an  excitement  of  the  emotions  of  a  more  or 
less  limited  kind,  we  find  a  variety  of  interesting  psychoses  which  have 
within  a  comparatively  recent  period  been  considered  under  the  names 
folie  du  doute?  or  Grubelsucht.^  These  terms  are  applied  to  the  condition 
of  mind  which  is  manifested  by  a  morbid  feeling  of  doubt  and  consequent 
indecision  under  the  most  ordinary  circumstances,  when  both  the  doubt 
and  indecision  are  unreasonable  in  the  extreme,  but  the  individual  under 
the  mandate  of  an  imperative  conception  yields  more  or  less  to  his  disor- 
dered emotions.    Some  years  ago  we  would  speak  of  this  condition  of 

1  I  have  adopted  this  term  because  as  far  as  I  know  there  is  no  proper  English  word, 
and  no  Greek  root  can  be  found  that  will  do.  The  morbid  state  of  mind  is  essentially 
introspective,  and  its  place  is  among  the  ps}rchoses  which  include  the  second  form  of 
hypochondriasis  of  Bucknill  and  Tuke. 

2  Ball,  L'Encephale,  Nov.  1882.  3  Griesinger. 


1885.] 


Hamilton,  Introspective  Insanity. 


131 


mind  as  "hysteria,"  or  if  it  influenced  the  patient's  conduct  to  any  re- 
markable degree  we  would  be  at  a  loss  for  a  proper  explanation.  Dr. 
Beard,  before  his  death,  in  writing  of  neurasthenia,  coined  many  long 
Greek  words  which  he  applied  to  the  different  forms  of  limited  emotiona 
trouble  ;  and,  since  his  time,1  Hammond  and  others  have  with  more  or 
less  success  distinguished  subdivisions  of  the  disorder.  It  would  be  unne- 
cessary to  more  than  allude  to  the  various  exceedingly  rare  kinds  of  morbid 
fears  which  symptomatize  the  disorder.  Agoraphobia  (fear  of  spaces)  is 
the  most  common,  and  has  been  described  by  Westphal,2  Gelineau,  Le 
Grand  du  Saulle,  Hammond,  Benedikt,  Tamburini,  and  others.  Another 
form  of  trouble  known  as  Claustrophobia*  was  applied  by  Ball  and  Mes- 
chede  to  that  state  which  is  symptomatized  hy  fear  of  confined  places, 
great  heights,  and  that  vague  discomfort  and  impulse  to  suicide  which  is 
experienced  by  those  individuals  who  are  exposed  to  peril,  especially  when 
the  facilities  for  self-destruction  are  near  at  hand.  This  term  in  some 
respects  is  a  misnomer,  and  only  half  expresses  the  condition.4  A  vague 
and  unreasonable  fear  of  the  elements  may  reach  the  dignity  of  insanity — 
for  instance,  Beard5  applied  the  term  Astraphobia6  to  the  fear  of  lightning, 
and  I  have  seen  patients  in  whom  the  fear  of  fire  or  water  has  led  them 
ultimately  to  do  strange  and  disorderly  actions.  Misophobia  has  been 
applied  by  Hammond7  to  the  dread  of  pollution  or  defilement.  It  would 
be  possible  .with  little  trouble  to  prepare  a  list  of  names  as  formidable  and 
curious  as  one  of  Rabelais's  tables,  or  the  roll-call  of  an  Indian  reservation, 
and  the  danger  of  making  the  subject  equally  ridiculous  is  very  great. 
Rush  first  wrote  upon  morbid  fears  in  the  following  quaint  way  :  "  These 
objects  of  fear  are  of  two  kinds — 1.  Reasonable.  These  are  death  and 
surgical  operations  ;  and  2.  Unreasonable.  These  are  thunder,  darkness, 
ghosts,  speaking  in  public,  sailing,  riding ;  certain  animals,  particularly 
cats,  rats,  insects,  and  the  like." — Loc.  cit.,  p.  325.  It  cannot  be  denied, 
however,  that  while  no  refinement  of  diagnosis  warrants  the  term  "  emo- 
tional monomania"  invented  by  Hammond,  the  condition  implies  a  limited 
emotional  excitement  of  a  depressing  nature,  and  either  as  an  element  of 
primary  insanity  or  as  a  precursor  to  some  form  of  general  intellectual 

1  A  Treatise  on  Insanity,  N.  Y.,  1883,  p.  400  et  seq. 

2  Archiv  fur  Psychiatrie  und  Nervenkrankheiten,  Band,  ii.,  H.  1,  p.  73,  1871. 

3  De  la  Claustrophobia,  B.  Ball,  Annales  MedicO-psychologiques,  1879,  p.  37S. 

4  "  Horreur  du  vide"  was  the  term  used  by  Bourdin. 

5  A  Practical  Treatise  upon  Nervous  Exhaustion,  p.  29. 

6  This  disease,  if  it  be  such,  was  fully  described  by  Rush.  "  A  lady  of  respectable 
character,  formerly  of  this  city,  usually  fainted  with  terror  during  the  time  of  a  thunder- 
gust,  and  discovered,  by  a  livid  countenance,  and  cold  and  clammy  sweats,  the  signs 
of  approaching  death.  She  was  apparently  kept  alive  by  pouring  into  her  stomach 
three  or  four  glasses  of  Jamaica  spirits  ;  it  was  remarkable  she  was  never  intoxicated 
by  it,"  etc. ;  also  see  pages  328,  329,  331. — Medical  Inquiries  and  Observations  upon 
the  Diseases  of  the  Mind.    Phila.  1812. 

7  Neurological  Contributions,  No.  1,  1879. 


132 


Hamilton,  Introspective  Insanity. 


[Jan. 


insanity  (usually  melancholia)  its  importance  cannot  be  questioned.  I 
have  yet  to  see  the  case,  however,  in  which  for  any  length  of  time  the 
insanity  was  confined  to  one  range  of  subjects  ;  the  mysophobia  is  sooner  or 
later  connected  with  sexual  perversion  or  religious  delusions,  and  the 
claustrophobia  becomes  "  suicidal  insanity." 

Tamburini,1  whose  reputation  for  analytical  research  and  exactness  is 
world-wide,  classifies  the  different  varieties  of  deh're  du  doute,  making  six 
subdivisions:  1st.  The  metaphysical,  which  implies  endless  queries  upon 
the  part  of  the  patient  of  a  purely  transcendental  kind.  2d.  The  form 
which  implies  doubt  about  trifles,  with  indecision  or  suspended  volition. 
3d.  "  The  scrupulous  variety,"  which  implies  "  morbid  conscientiousness 
respecting  matters  unrelated  to  the  domain  of  ethics."  4th.  The  form  "in 
which  the  patient  has  a  morbid  fear  of  compromising  himself  by  very  un- 
important acts."  5th.  The  calculating  variety.  6th.  The  tactile  variety? 
which  includes  mysophobia. 

This  grouping  of  the  various  manifestations  of  deh're  da  doute  is  much 
more  satisfactory  than  the  formulation  of  Beard  or  others. 

The  state  of  mind  which  is  manifested  in  morbid  doubt  determines  to  a 
greater  or  less  extent  the  conduct  of  the  subject.  To  the  unbalanced 
discrimination  is  added  a  tendency  to  avoid  the  objects  which  act  as  emo- 
tional excitants,  or  to  toucli  certain  things — for  no  reason  whatever  usually, 
or  because  there  is  a  source  of  impending  danger — a  penalty  for  the 
omission  to  do  so.  To  this  condition  of  mind  the  term  delire  du  toucher 
has  been  applied.  There  are  many  eccentric  or  hysterical  persons  in  whom 
there  is  no  reason  to  suspect  that  insanity  exists,  wTho  are  impelled  to  gratify 
certain  tactile  longings,  if  such  an  expression  is  allowable.  No  less  a  per- 
sonage than  Ben  Johnson  was  in  the  habit,  in  his  daily  walks,  of  placing 
his  hand  upon  every  door  step  or  alternate  door  step,  or  every  lamp-post, 
and  if  he  missed  one  he  invariably  turned  back.  In  such  cases  as  this  the 
performance  is  simply  the  relief  of  an  active  mind — an  automatic  act — when 
it  is  the  result  of  a  superabundance  of  energy — but  such  a  condition  may 
amount  to  insanity  when  it  requires  the  entire  attention  of  the  individual, 
and  becomes  a  voluntary  act  which  involves  painful  reasoning  with  self. 

We  constantly  meet  with  examples  of  what  are  simply  regarded  as 
"timidity"  or  "nervousness."  In  this  category  we  find  the  young 
women  who  look  under  their  beds  or  into  their  bureau  drawers  for  con- 
cealed burglars.  Such  actions  and  others,  when  there  is  the  knowledge 
of  their  uselessness,  and  when  there  is  an  imperative  impulse  to  persist, 
may  become  so  grave  as  to  fill  the  individual  with  terror  if  he  or  she  does 
not  yield,  and  there  may  be  actual  mental  distress  and  physical  torture, 
which  may  completely  demoralize  the  sufferer.    This  condition  is  closely 

1  Revista  Sperimentale  e  di  Freniatria,  etc.,  see  abstracts  in  Journal  of  Nervous  and 
Mental  Disease,  Oct.  1883. 


1885.] 


Hamilton,  Introspective  Insanity. 


133 


allied  to  the  self-recrimination  of  the  ill-balanced  person  of  religious  turn 
of  mind,  who  fancies  he  has  been  remiss  in  some  trivial  duty. 

Many  cases  of  this  kind  have  fallen  under  my  notice  both  among 
women  and  men.  I  cannot  regard  them  as  unusual ;  I  will,  however,  report 
two  or  three  examples  of  introspective  insanity,  which  are  curious  in  the 
extreme,  for  the  purpose  of  considering  their  etiology  and  treatment. 

The  first  is  one  in  regard  to  which  I  was  consulted  by  Dr.  E.  H. 
Nicholls,  of  the  U.  S.  Marine  Hospital  Service,  and  I  shall  make  use  of 
his  letter.    Dr.  Nicholls  wrote  to  me  in  September,  1884  

Case  I.  "  The  patient  is  a  man  34  years  old,  apparently  in  good 
health  and  humor.  Slightly  built,  typical  nervous  temperament,  good 
figure,  mathematical  in  everything  he  does,  fastidiously  neat  in  person, 
good  address,  and  perfect  manners,  has  seen  much  of  the  world,  and  is 
highly  educated.  Was  in  good  health  up  to  1876,  when  he  was  subjected 
to  an  epidemic  of  yellow  fever,  although  he  did  not  contract  the  disease, 
but  a  protracted  dyspepsia  followed  for  four  years.  Dipsomania  appeared, 
drinking  frequently,  and  continuing  until  he  was  confined,  and  then  he 
would  taper  off,  and  for  two  months  would  enjoy  good  health,  then  re- 
peating the  spree  with  the  same  result.  He  used  tobacco,  morphine,  and 
alcohol,  morphine  (only  at  night  gr.  Five  years  ago  he  reformed 

every  bad  habit,  and  up  to  one  year  ago  had  none,  when  he  again  com- 
menced smoking  four  cigars  a  day,  which  seemed  to  improve  his  digestion. 
He  had  never  been  in  good  health  since  '76.  Neurasthenic  in  a  marked 
degree,  but  his  intelligence  suppressed  many  outbreaks  except  the  symptoms 
I  will  presently  ask  you  about.  His  digestion  is  poor  at  times,  causes 
change  of  diet  continually ;  sometimes  despondent,  then  emotionally 
elated ;  apparently  he  is  healthy  enough.  Urine  normal,  sometimes 
phosphatic.  Indulges  twice  a  week  with  women.  He  had  been  living  by 
the  rule  of  arithmetic  ....  At  times  his  passages  look  like  putty. 
No  pain  in  any  part  of  body  on  pressure.    There  is  no  history  of  syphilis." 

The  doctor  thus  detailed  his  patient's  peculiar  mental  con- 
dition. "  While  awake  he  has  a  nervous  unrest,  and  in  attending  his 
duties  something  seems  to  dictate  the  particular  direction  of  his  walk,  for 
example,  if  he  comes  to  a  stone  or  any  object  in  the  road,  something 
seems  to  say,  '  you  must  go  to  the  right' — of  the  stone  or  object — or  to  the 
left  as  the  case  may  be,  and  he  is  obliged  to  obey  or  there  seems  to  his 
mind  some  severe  penalty  or  unforeseen  danger  that  will  befall  him  if  he 
disobeys  in  the  slightest  degree  this  despotic  dictate.  It  not  only  happens 
in  circumstances  like  the  above,  but  in  almost  anything.  In  eating  the 
same  despot  says,  for  example,  '  you  must  eat  that  potato  before  you  eat 
your  rice,'  or  in  dressing,  4  you  must  put  on  your  right  shoe  before  your 
left,'  or,  '  don't  turn  that  corner  before  you  spit.'  So  he  has  to  stop 
and  spit  before  he  turns.  The  most  horrible  penalties  seem  to  hover 
about  him,  to  fall  upon  him  should  he  disobey  these  ridiculous  suggestions. 
Mark,  these  only  occur  when  on  his  feet  or  sitting.  When  in  bed  he 
sleeps  well  and  feels  well,  but  as  soon  as  he  touches  the  floor  on  rising  in 
the  morning  these  phenomena  commence  and  continue  all  day  unless 
mentally  very  much  occupied." 

I  wrote  to  Dr.  Nicholls  giving  the  diagnosis  "  Folie  du  doute"  with 
"  delire  du  toucher,"  and  suggesting  moral  therapeutics.  A  few  weeks 
after  the  following  letter  came  : — 


134 


Hamilton,  Introspective  Insanity. 


[Jan. 


"  There  are  some  other  points  I  neglected  to  inform  you  about.  This 
patient  has  had  misophobia  to  a  marked  degree  for  eight  years,  but  not 
so  much  of  late,  two  years.  His  personal  appearance  constantly  occupy- 
ing his  attention,  dusting  his  clothes,  washing  his  hands,  cleansing  his 
teeth,  fear  of  shaking  hands  with  any  one  he  suspects  to  be  diseased,  not 
drinking  from  cups  used  by  others,  morbid  fear  of  venereal  disease,  afolie 
du  doute  annoys  him.  If  he  locks  a  door  or  trunk,  he  will  return  to  see 
if  it  is  done.  Reading  letters  over  two  or  three  times.  Hesitating  which 
way  to  do  things  in.  The  delire  du  toucher  he  has  almost  conquered,  as  he 
thinks  it  all  foolishness  and  cannot  see  any  reason  in  it.  Since  your  first 
letter  the  imperative  impulses  have  diminished,  as  he  has  faithfully  resisted 
their  demands  and  no  longer  feels  that  punishment  will  follow  his  resist- 
ing the  ridiculous  promptings.  Your  letter  encouraged  him  more  than 
anything  else,  and  I  feel  certain  he  will  perform  what  he  undertakes, 
notwithstanding  the  impulse  continues  some  time  longer.  I  presume  his 
case  is  one  of  abortive  monomania.  About  once  a  month  his  liver 
troubles  him  greatly  ;  terrible  indigestion.  His  stools  very  light  colored 
and  consisting  of  balls  of  various  shapes."  ....  Mercurials  benefit 
him  ;  this  trouble  seems  to  be  connected  with  hepatic  atony.  The  patient 
has  always  been  hypochondriacal. 

The  following  is  a  most  extraordinary  case  of  a  sexual  form  of  intro- 
spective insanity. 

Case  II.  Mr.  M.,  is  a  young  broker  of  twenty-three,  who  has  led  an 
active  and  rather  fast  life.  He  several  years  ago,  when  little  more  than 
a  boy,  married  a  woman  older  than  himself,  and  lived  with  her  for  two 
years.  Immediately  after  his  marriage  he  was  seized  with  doubts  and 
fears  regarding  the  stability  of  his  happiness,  and  speculations  whether  he 
had  done  right  in  forming  the  alliance.  He  could  not  make  up  his 
mind,  and  being  a  man  of  few  resources  he  busied  himself  in  his  exciting 
work,  and  stayed  much  away  from  home.  For  reasons  which  I  have  not 
clearly  made  out,  but  suspect  were  due  to  his  desertion  of  his  wife,  she 
obtained  a  divorce,  and  according  to  his  story  he  experienced  a  feeling  of 
relief  that  was  indescribable.  About  one  year  ago  while  at  a  boarding 
house  he  met  a  young  woman  of  pleasing  address,  and  within  two  months 
became  engaged  to  her.  He  regretted  the  step  almost  as  soon  as 
he  had  taken  it,  and  was  unhappy  in  the  extreme.  There  seemed  no 
reason  for  his  aversion,  for  she  was  pleasant  and  comely,  but  in  his  words, 
"  I  was  drawn  to  her  by  a  species  of  fascination  I  could  not  resist, 
although  I  had  begun  to  abhor  her."  Months  passed,  and  still  he  was 
tortured  by  doubts  which  rendered  him  miserable  both  mentally  and 
physically.  He  grew  thin  and  pale,  and  solicitous  about  his  condition, 
and  his  fiancee  asked  for  an  explanation.  Though  longing  for  a  severance 
of  the  ties,  and  according  to  his  admission  not  restrained  by  any  sense  of 
honor — he  felt  that  an  explanation  would  bring  some  terrible  calamity. 
Several  times  he  went  to  Philadelphia,  thinking  that  the  change  would 
bring  rest  and  relief,  but  when  he  reached  his  destination  he  was  filled 
with  an  irresistible  longing  to  return.  He  would  frequently  after  making 
arrangements  to  stay  away  for  several  days  return  by  the  first  train,  and 
sit  outside  of  the  house  of  his  fiancee  until  dawn.  His  feeling  was  always 
one  of  strong  repulsion.  His  conduct  and  procrastination  so  saddened  the 
young  lady  that  she  counselled  with  her  parents,  and  he  was  requested  to 
lix  a  day.    Upon  the  advice  of  a  friend  to  whom  he  had  appealed,  he  re- 


188.5.] 


Hamilton,  Introspective  Insanity. 


135 


turned  to  explain  matters  and  seek  release,  but  his  good  resolution  changed 
and  he  chose  the  other  course.  Even  the  advice  of  a  distinguished  neurolo- 
gist in  another  city  whom  he  had  consulted,  and  which  he  agreed  to  abide 
by,  was  disregarded  almost  immediately.  He  was  married  and  was  power- 
less to  do  his  duty,  and  arose  from  the  bed  with  a  feeling  of  loathing  and 
disgust  for  his  wife.  The  next  day  he  sought  the  society  of  a  prostitute, 
and  obtained  immediate  relief  and  pleasure.  He  spent  several  days  with 
her,  but  the  old  feeling  of  attraction  returned,  and  he  again  sought  his 
wife.  According  to  his  story,  he  wished  to  spare  her  all  pain,  and  tried  to 
conceal  his  disgust.  He  admitted  his  condition  of  mind,  and  cried  because 
of  his  weakness.  It  was  alternate  repulsion  and  attraction,  a  species  of 
fascination. 

The  patient  is  a  respected,  honorable,  amiable  man,  and  with  the 
exception  of  his  infirmity  is  apparently  sane.  His  relations  with  his 
business  associate  and  with  his  own  family  are  in  every  way  creditable  ajid 
proper.  The  patient's  manner  when  I  saw  him  was  exceedingly  restless, 
and  his  mental  torture  was  so  great  that  his  physician  to  whom  he  had 
confided  his  secret  feared  he  would  commit  suicide,  whilst  his  distress  lest 
his  wife  should  know  his  feelings  was  genuine  and  sincere.  I  advised 
separation  for  a  time,  but  when  I  last  heard,  I  found  he  was  not  able  to 
stay  away  from  his  wife.  In  this  case  there  was  history  of  insanity  in 
the  male  line. 

The  following  case  is  one  possessing  interest,  from  the  fact  that  the 
individual  came  of  neurotic  stock,  that  his  morbid  mental  condition  was 
largely  the  result  of  early  errors  in  education,  and  that  his  imperative 
conceptions  were  so  powerful. 

Case  III.  Mr.  V.,  a  middle-aged  man,  is  the  son  of  parents  of  the 
insane  temperament,  and  several  cases  of  insanity  among  his  ancestors  have 
been  known.  These  have  as  a  rule  been  of  the  melancholic  type.  Mem- 
bers of  the  patient's  immediate  family  are  eccentric.  At  an  early  age  he 
manifested  evidences  of  an  emotional  temperament,  and  was  always 
morbidly  conscientious.  His  interpretation  of  the  Scriptures  was  literal 
in  the  extreme,  and  the  practical  expression  of  his  views  rendered  him 
ridiculous  at  school.  Though  possessed  of  manliness  and  courage,  he 
frequently  allowed  himself  to  be  whipped  by  other  boys,  submitting 
because  he  believed  it  to  be  his  Christian  duty,  and  afterwards  spent 
whole  hours  in  self-humiliation.  In  college  he  was  a  good  student  and 
much  liked,  and  when  he  left  he  took  a  lively  interest  in  worldly  affairs, 
and  seemed  to  be  bright  and  gay.  A  sense  of  duty  prompted  him  to  study 
for  the  ministry,  a  profession  which  for  many  reasons  was  disagreeable  to 
him.  After  his  ordination  he  met  and  married  a  most  charming,  sensible 
woman.  About  this  time  (about  twelve  years  ago)  he  conceived  the  idea 
that  it  was  his  duty  to  go  as  missionary  to  Africa,  but  this  step  was  dis- 
tasteful to  him  in  the  extreme.  At  the  last  moment  he  changed  his  mind, 
but  no  sooner  had  he  done  so  than  he  became  possessed  with  a  new  yearn- 
ing to  take  the  step.  It  was  pointed  out  that  he  was  not  suited  for  the  life, 
and  for  a  time  he  seemed  convinced,  but  the  next  day  after  a  sleepless 
night  he  would  bring  himself  to  something  like  a  fixed  resolution,  but 
it  would  fall  to  the  ground,  and  apparently  for  no  sufficient  reason  he 
would  complain  in  great  wretchedness  of  his  indecision.  Had  this 
occurred  but  once  or  twice,  no  more  importance  could  be  attached  to  it 


136 


Hamilton,  Introspective  Insanity. 


[Jan. 


than  to  the  vacillation  of  a  weak  man,  but  it  has  lasted  for  twelve  years. 
He  is  daily  troubled  by  this  indecision.  He  endeavors  to  escape  from 
things  which  suggest  the  all-absorbing  thought,  but  he  seems  impelled  to 
seek  the  society  of  persons  engaged  in  missionary  work,  and  of  clerical 
friends,  with  some  of  whom  he  has  gone  over  the  same  ground  repeatedly. 
He  goes  to  bed  in  an  apparently  peaceful  frame  of  mind,  but  soon  arises  and 
goes  to  his  library  where  he  spends  the  remainder  of  the  night  in  tears, 
arguing  with  himself.  He  leaves  a  concert  room  in  the  midst  of  the  per- 
formance, or  cuts  short  his  horseback  ride.  At  the  table  he  without  any 
apparent  reason  precipitately  bursts  into  tears.  A  trip  to  Europe  did  no 
good.  One  day  he  would  take  measures  to  sell  his  house  and  put  his  affairs 
in  order  to  leave  the  country  for  the  field  of  his  missionary  work  ;  the  next 
he  would  change  his  mind.  He  is  constantly  in  doubt.  He  has  been  for- 
bidden to  read  certain  books,  but  an  irresistible  impulse  compels  him  to 
ta»ke  them  from  their  shelves.  Up  to  a  few  months  ago  the  patient  pre- 
sented nothing  but  the  symptoms  detailed.  He  was  and  is  now  a  very 
intelligent  and  agreeable  man,  but  lately  he  has  several  times  spoken  of 
suicide,  and  has  been  quite  violent  in  other  ways,  so  that  measures  of 
protection  are  necessary. 

The  last  case  is  one  of  a  familiar  type,  but  somewhat  unusual  in  its 
manner  of  expression. 

Case  IV.  Mrs.  B.  is  a  married  woman  of  38  years,  whose  father  and 
other  relatives  died  insane.  A  few  months  after  the  birth  of  a  child,  and 
after  a  perfectly  natural  labor,  she  left  her  bed.  She  was  strangely  ner- 
vous and  tearful.  With  her  husband  she  came  to  my  office  and  told  me 
her  story.  She  had  no  worry  and  no  cares,  and  had  every  reason  to  be 
happy,  except  that  she  was  constantly  possessed  with  the  idea  that  she 
must  do  herself  harm,  as  well  as  her  child  who  slept  in  her  room.  She 
very  clearly  detailed  to  me  the  horrible  fear  that  possessed  her  that  she 
might  kill  her  baby,  and  spoke  of  various  plans  that  had  suggested  them- 
selves. She  could  not  bear  the  sight  of  cutting  instruments  of  any  kind 
and  she  pictured  the  keen  blade  of  a  knife  crossing  her  throat.  She  per- 
fectly knew  the  terrible  nature  of  her  doubts,  and  not  feeling  sure  of 
her  own  self-reliance,  ordered  that  all  of  these  things  be  taken  away  from 
her  room.  Not  only  was  she  tortured  by  the  idea  that  she  might  do  her- 
self harm,  but  she  imagined  in  what  way  she  might  assassinate  her  hus- 
band or  nurse.  Her  terror  became  so  great  that  she  ordered  all  the  globes 
to  be  removed  from  the  gas  chandeliers,  and  the  glass  ornaments  to  be  taken 
from  the  mantel-piece.  When  she  rode  in  her  brougham,  she  thought  how 
easy  it  would  be  to  break  one  of  the  windows  and  kill  herself  with  the 
glass.  Before  she  left  home  she  substituted  dull  silver  knives  for  those  of 
steel  she  had  been  in  the  habit  of  using.  In  this  patient  there  were  symp- 
toms of  claustrophobia.  She  occupied  a  room  in  the  upper  story  of  a 
large  hotel,  where  she  was  taken  at  my  suggestion,  and  she  confessed  to 
me  her  frequent  temptation  to  jump  out. 

In  this  case  there  were  absolutely  no  signs  of  mental  disturbance 
except  that  I  have  detailed.  She  was  able  to  fully  realize  her  horrible 
infirmity,  and  her  grief  lest  she  should  be  unable  to  resist  her  half- 
formed  promptings  was  perfectly  sincere.  She  became  very  miserable, 
reduced  in  flesh,  anaemic,  and  suffered  from  gastric  disorders  of  ner- 


1885.] 


Hamilton,  Introspective  Insanity. 


137 


vous  causation.  Attacks  of  palpitation,  flatulence,  and  sinking,  with 
obstinate  constipation,  were  present  for  several  months.  Her  urine  was 
free  from  albumen,  but  was  loaded  with  phosphates  and  urates.  Her 
tongue  was  furred  in  the  centre  and  red  at  the  edges,  and  her  circulation 
was  very  defective.    She  ultimately  recovered,  though  not  perfectly. 

This  case  is  one  of  a  most  common  class,  and  most  likely  to  be  mis- 
understood ;  I  have  known  several  suicidal  lunatics  whose  trouble  began 
first  in  this  manner  and  was  for  a  long  time  disregarded. 

In  these  cases  there  was  a  history  of  insanity,  and  with  the  exception 
of  that  of  Mr.  M.  the  nervous  temperament  was  manifested  by  various 
peculiarities,  more  often  by  a  species  of  hypochondriasis,  by  peculiarities  of 
temper,  and  by  acts  of  eccentricity  which  caused  the  subjects  to  be  looke^d 
upon  as  "queer."  The  history  of  dipsomania  in  the  case  of  Dr.  Nicholls's 
patient  is  suggestive,  and  though  the  immediate  prospects  for  recovery 
are  good,  I  am  inclined  to  think  that  the  possibility  of  development  of 
some  grave  form  of  mental  trouble  is  very  great.  I  have  already  alluded 
to  the  difficulty  of  isolating  these  forms  of  morbid  fear,  I  may  add  that  I 
have  noticed  not  only  mysophobia  as  an  early  symptom  of  a  very  serious 
variety  of  chronic  mental  derangement,  but  delire  du  doute  as  well,  and 
that  too  when  there  was  no  associated  delusion.  The  "  cursed  spot"  of 
Lady  Macbeth  was  the  somnambulistic  mysophobia  of  an  agitated  mind. 
The  fear  of  contamination  which  is  found  in  the  waking  hours  is  of  a 
different  nature.  I  do  not  speak  of  those  cases  where  the  patient  believes 
herself  to  be  the  anointed  of  God,  and  fears  contamination,  or  to  the 
patient  who  as  the  result  of  an  hallucination  believes  his  hands  to  be 
covered  by  spiders  ;  but  to  the  victim  of  unreasonable  fears  which  are  out 
of  all  proportion  to  real  danger.  Recrimination  and  remorse  because  of 
unperformed  duties  are  familiar  enough  to  all  who  have  much  to  do  with 
the  insane.  In  one  case  of  climacteric  insanity  that  comes  to  mind,  the 
condition  of  the  patient  in  this  respect  was  akin  to  the  lighter  trouble 
which  I  have  considered  as  introspective  insanity.  In  this  case  the  patient 
frequently  referred  to  certain  days  much  after  this  fashion:  "  Ah,  it  is  the 
twenty-third  of  April ;  had  I  not  taken  the  step  I  did  upon  the  twenty- 
third  of  March  all  would  not  now  be  useless."  It  seemed  that  upon  the 
twenty-third  of  March  she  had  taken  food  which  she  conceived  had  intro- 
duced a  devil  into  her  stomach.  This  reversion  to  days  and  anniversaries 
occurred  frequently,  and  she  accurately  fixed  certain  occasions  which 
were  events  more  or  less  important,  and  her  doubts  and  regrets  were  of 
the  most  painful  kind. 


138 


Eliot,  Poliomyelitis  Anterior  in  Adults. 


[Jan. 


Article  XI. 

Poliomyelitis  Anterior  in  Adults.    By  Gustavus  Eliot, 
A.M.,  M.D.,  of  New  Haven,  Connecticut. 

To  make  the  diagnosis  of  a  rare  disease,  or  of  an  uncommon  disease 
occurring  under  unusual  circumstances,  is  always  gratifying  to  the  physi- 
cian. But  of  incomparably  greater  importance  to  both  patient  and  practi- 
tioner is  the  selection  of  a  plan  of  treatment  which  will  remove  the  annoying 
symptoms.  It  is  especially  in  diseases  which,  while  they  sometimes  recover 
spontaneously,  on  the  other  hand  more  often  are  followed  by  protracted 
convalescence  or  incomplete  recovery,  that  self-interest  and  humanity 
alike  demand  extreme  care  in  the  application  of  remedial  agents.  In  the 
successful  treatment  of  these  cases  one  realizes  the  inestimable  value  of 
scientific. therapeutics. 

Less  than  eight  years  ago  Dr.  E.  C.  Seguin,  of  New  York,  published  a 
small  volume  on  Myelitis  of  the  Anterior  Horns.  This  included  an 
analysis  of  forty-five  cases  of  the  disease,  of  which  nine  had  fallen  under 
the  personal  observation  of  the  author,  one  had  been  communicated  by 
Dr.  G.  M.  Beard,  three  had  been  reported  by  Dr.  W.  A.  Hammond  in 
his  Treatise  on  the  Diseases  of  the  Nervous  System,  one  by  Dr.  D.  F. 
Lincoln  in  the  Boston  Medical  and  Surgical  Journal,  and  the  remainder 
by  various  foreign  authors.  During  subsequent  years  a  number  of  cases 
have  been  reported  in  this  country.  Among  those  which  have  come  to 
my  notice  are  five  by  Dr.  Wharton  Sinkler,  of  Philadelphia,  and  two  by 
Dr.  Julius  Althaus,  of  London,  in  the  American  Journal  of  the 
Medical  Sciences  for  1878;  and  one  each  by  Dr.  J.  Van  Duyn,  of 
Rochester,  and  Dr.  A.  Ranney,  of  New  York,  in  the  Archives  of  Medi- 
cine for  1884.  Translations  of  works  by  Erb,  Charcot,  and  Rosenthal 
also  contain  histories  of  cases. 

The  neurologists  have  at  length  established  the  possibility  of  the  occur- 
rence in  adults  of  a  form  of  paralysis  closely  resembling  the  well-known 
infantile  spinal  paralysis.  Kussmaul,  of  Freiburg,  and  his  pupil  Frey, 
called  it  poliomyelitis  anterior.  It  is  now  easy  for  a  physician  familiar 
with  the  literature  of  diseases  of  the  spinal  cord  to  make  the  diagnosis,  if 
a  case  of  this  particular  disease  happens  to  consult  him.  Having  myself 
had  the  good  fortune  to  meet  with  such  a  case,  I  will  introduce  the  history 
here. 

Case  of  Subacute  Poliomyelitis  Anterior  in  an  Adult — Feb.  19,  1884. 
Mr.  D.  was  born  in  Ireland,  is  twenty  years  of  age,  and  has  lived  in  New 
Haven  two  and  a  half  years.  There  is  no  history  of  insanity  in  the  family. 
His  mother  and  sister  are  both  living.  His  father  died  of  consumption 
November  14,  1883.  The  patient  was  married  July  3,  1883,  and  has  no 
children.  For  several  weeks  his  home  has  been  in  a  basement.  He  denies 
having  had  venereal  disease,  as  well  as  addiction  to  venereal  excesses.  He 


1885.] 


Eliot,  Poliomyelitis  Anterior  in  Adults. 


139 


has  been  in  the  habit  of  using  a  little  alcohol,  tobacco,  and  weak  tea,  and 
no  coffee.  He  suffered  from  chills  and  fever  three  or  four  years  ago,  but 
has  had  no  other  illness.  Since  September  20,  1883,  he  has  been  employed 
as  brakeman  on  a  freight  train,  which  every  night  runs  sixty  miles  and 
return.  While  at  the  farther  end  of  the  trip  he  has  often  been  obliged  to 
run  through  snow  and  water  so  that  his  clothing  became  thoroughly  soaked 
as  high  as  the  waist.  For  several  weeks  previous  to  the  death  of  his 
father  he  lost  a  great  deal  of  sleep  taking  care  of  him,  and  suffered  a  great 
deal  of  anxiety.  Subsequently  he  had  a  severe  cold.  A  year  ago  he 
weighed  185  pounds,  but  during  the  winter  he  lost  flesh,  so  that  before  the 
present  illness  came  on  his  weight  was  only  155  pounds. 

For  three  weeks  he  has  noticed  a  weakness  in  both  legs,  so  that  he  tires 
easily  when  walking,  and  cannot  go  up  stairs,  climb  a  ladder,  or  step  up 
on  a  car  or  into  a  carriage  as  easily  as  formerly.  This  symptom  was  pre- 
ceded by  what  he  describes  as  "  a  tightening  of  the  sinews"  in  the  calves 
of  both  legs.  This  was  not  a  cramp,  and  did  not  draw  his  leg  up,  but 
"  the  sinews  felt  as  if  they  were  drawn  up,"  and  he  "  could  not  straighten 
the  legs  without  feeling  it."  He  did  not  experience  this  sensation  when 
quiet,  but  only  when  he  walked.  In  two  days  he  could  not  run.  In  two 
or  three  weeks  the  trouble  came  in  his  arms,  but  they  were  affected  some- 
what differently.  There  was  weakness,  but  no  "  tightening  of  the  sinews." 
The  legs,  thighs,  forearms,  and  arms  all  grew  smaller.  For  two  or  three 
days  there  was  a  little  formication  in  the  legs  and  arms,  but  no  pricking 
sensations.  Two  and  a  half  weeks  after  the  weakness  was  first  noticed 
numbness  came  on.  Now  there  is  pain  in  the  calves  of  the  legs,  and 
numbness  in  the  legs  from  the  knees  down  but  not  above,  most  marked 
behind,  and  in  the  hands  below  the  wrists.  Both  sides  are  affected  alike, 
and  the  arms  were  involved  three  weeks  later  than  the  legs.  There  has 
been  no  anaesthesia,  no  sensation  of  a  band  around  the  body,  and  no  cold- 
ness or  blueness  of  the  extremities.  He  has  had  no  chills.  Two  weeks 
after  the  weakness  commenced  he  was  "  a  little  feverish"  for  a  single  day. 
There  has  been  no  unusual .  sweating.  At  first  the  skin  was  "  dry  and 
parched"  for  a  few  days.  The  numbness  came  on  a  week  later.  Three 
or  four  weeks  before  the  loss  of  strength  was  first  noticed  there  was 
diminution  of  vision  so  that  he  could  not  easily  read  a  newspaper.  This 
soon  passed  away.  He  is  sleepy  all  the  time,  and  sleeps  a  great  deal. 
The  bowels  move  every  day,  but  not  freely.  Electricity  has  been  applied 
twice  by  a  quack.  R. — Ex.  cascarae  sagradae,  f'Jij  ;  tr.  calumbae,  q.  s.  ad 
§iij — M.    Sig.  3j  before  eating. 

26th.  The  patient  took  the  medicine  three  times  a  day  and  finished  it 
day  before  yesterday  at  noon.  It  caused  improvement  of  appetite,  and 
two  or  three  loose  painless  movements  of  the  bowels  each  day.  It  is  now 
nearly  a  month  since  he  noticed  the  first  symptoms,  and  they  are  steadily 
increasing.  The  legs  are  growing  weaker.  The  hands  are  not  much 
weaker.  There  are  no  pains  or  cramps,  only  weakness.  Some  tremor  is 
observable  in  the  legs,  arms,  and  tongue.  Patellar  reflex  is  absent. 
There  is  no  anaesthesia.  Once  in  three  or  four  days  he  feels  "a  weakness 
across  the  kidneys."  There  is  no  oedema,  and  he  has  noticed  no  change 
in  the  urine.  He  sleeps  well,  and  has  had  no  headache  lately.  The  tongue 
is  broad  and  has  a  thin  gray  coating.    Pulse  60.    R. — Pil.  cinchonidinae 

sulph.,  aa  gr.  ij,  No.  xxiv.    Sig.  one  t.  i.  d.,  before  eating.     R  Sodii 

bromidi,  §ss ;  sodii  bicarbonatis,  3j  ;  tr.  belladonnas,  5'j;  aquae,  q.  s.  ad 
giij. — M.    Sig.  3j  -A-  M.  and  P.  M.,  5'j  at  evening,  in  water. 


140 


Eliot,  Poliomyelitis  Anterior  in  Adults. 


[Jan. 


March  5.  While  taking  the  last  medicine  his  mouth  became  dry, 
and  the  weakness  increased  more  rapidly  than  before.  He  is  now  so 
weak  that  he  can  only  walk  a  very  short  distance.  Advised  the  applica- 
tion of  strong  mustard  pastes  over  the  back  between  the  shoulders  and  in 
the  lumbar  region. 

1th.  After  he  stopped  taking  the  belladonna  and  bromide,  he  ceased 
to  grow  worse.  The  involuntary  muscular  movements  are  gradually 
diminishing.  On  account  of  the  weakness  he  has  been  obliged  to  keep 
quiet  and  not  walk  about  much.  Mustard  was  applied  to  rubefaction  over 
spaces  six  inches  square  between  the  shoulders  and  "  over  the  kidneys." 
R — Liquor,  ergotae  purificati,  3vj  ;  potassii  iodidi,  5iij  ;  syr.  sarsaparillae 
comp.,  q.  s.  ad  ^iv. — M.  Sig.  3j  t.  i.  d.,  in  water.  Recommend  also 
bathing  the  limbs  in  hot  water  with  salt  and  mustard,  and  rubbing  them 
with  whiskey. 

\Uh.  The  patient  finished  the  medicine  day  before  yesterday.  For 
three  nights  he  bathed  his  limbs  with  whiskey.  Then,  commencing  March 
11,  he  used  "gargling  oil"  four  mornings  and  two  nights.  The  last  two 
nights  he  has  used  the  mustard  and  salt  in  hot  water  as  directed.  The 
weakness  commenced  to  go  away  March  10.  The  legs  and  arms  are 
stronger.  There  is  still  numbness  in  both  hands  and  feet.  It  is  nearly 
all  gone  from  the  back  of  the  legs.  The  bowels  have  moved  every  day 
but  one;  the  appetite  is  good,  and  he  sleeps  well.  Continue  the  treat- 
ment without  change. 

21st.  The  last  of  the  medicine  was  taken  yesterday  morning.  The 
patient  has  bathed  his  forearms  and  his  legs  to  above  the  knees  with 
whiskey  twice  a  day,  and  has  used  no  other  medicine.  He  feels  a  great 
deal  better,  and  is  stronger  in  his  legs  and  arms  ;  the  legs  in  particular 
are  a  great  deal  stronger,  so  that  now  he  can  go  up  and  down  stairs.  The 
numbness  is  entirely  gone  from  his  legs,  but  not  completely  from  his  arms. 
His  shoulders  feel  stiff.  There  is  no  headache,  and  no  pain  or  weakness 
in  the  back.  The  stomach  and  bowels  continue  in  good  condition,  and  he 
sleeps  well,    Continue  the  same  treatment  as  before. 

28th.  The  patient  took  the  last  of  the  medicine  day  before  yesterday 
in  the  morning.  It  did  not  perceptibly  affect  his  head,  stomach,  or 
bowels.  He  has  also  rubbed  his  legs  with  whiskey.  He  continues  to  gain 
strength  in  his  legs  and  arms.  The  numbness  is  all  gone,  except  a  little 
in  the  hands  when  he  leans  upon  his  arms.  He  went  to  work  March  25, 
starting  out  on  a  freight  train  at  8.25  P.  M.,  running  sixty  miles  and 
return,  arriving  in  the  city  at  6.35  A.  M.  He  has  only  been  out  this  one 
night,  and  was  then  assisted  by  his  fellow-workmen.  Afterwards  he  felt 
sore  in  his  muscles,  but  otherwise  no  worse.     R. — Liq.  ergotae  pur.,  fjfss  ; 

potassii  iodidi,  3ij  ;  aquae,  ^ij  ;  syr.  sarsaparillae  comp.,  q.  s.  ad  f^iv  M. 

Sig.  3j  t.  i.  d.,  before  eating. 

April  8.  Finished  the  medicine  day  before  yesterday.  Continues  to 
rub  his  legs  once  a  day  with  whiskey.  His  weight,  which  when  he  was 
worst  was  reduced  to  142  pounds,  has  increased  to  161  pounds.  There  is 
still  some  weakness  in  the  legs  and  arms,  but  no  numbness.  Since  the 
last  visit  he  has  run  on  the  train  three  times,  and  has  done  all  his  work. 
He  can  jump  up  on  a  car,  or  run  up  and  down  stairs,  but  is  not  as  strong 

as  formerly.    He  feels  good  in  everyway.    R  Liq.  ergotae  pur.,  f'5iij  ; 

potassii  iodidi,  3iss;  aquae,  ^ij  ;  syr.  sarsaparillae  comp.,  q.  s.  ad  f^iv. — M. 
Sig.  3j  t.  i«  d.,  in  water. 


1885.] 


Eliot,  Poliomyelitis  Anterior  in  Adults. 


141 


22a?.  He  has  taken  no  medicine  for  a  week,  and  is  improving  steadily. 
He  has  been  running  on  the  cars  every  night  but  one  since  his  last  visit. 
His  natural  strength  is  not  fully  restored,  but  is  returning  gradually.  Last 
autumn  he  could  lift  800  pounds,  now  he  cannot  lift  400.  He  can  "jump 
around"  almost  as  fast  as  ever,  and  do  his  ordinary  work  as  well  as  ever. 
The  arms  and  legs  are  a  little  slimmer  than  they  used  to  be.  There  is  no 
disturbance  of  sensation.  The  patellar  reflex  is  still  absent.  Dismissed 
cured. 

Aug.  17.  With  my  friend,  Dr.  Frank  H.  Whittemore,  I  had  an  oppor- 
tunity of  examining  my  former  patient.  He  is  still  employed  as  a  brake- 
man  on  a  night  freight  train,  and  has  no  difficulty  in  doing  his  regular 
work.  His  weight  is  1 42  pounds  ;  he  thinks  his  limbs  are  as  large  in  pro- 
portion to  his  weight  as  they  ever  were,  but  they  are  not  as  large  as  they 
were  two  years  ago.  There  has  been  no  change  in  his  sexual  feeling  or 
power.  The  muscles  of  the  thenar  eminences  are  atrophied.  His  grip  is 
very  feeble  for  a  man  of  his  apparent  strength.  All  the  muscles  of  both 
upper  and  lower  extremities  respond  to  the  faradic  current.  There  are  no 
disturbances  of  sensation.  The  patellar  reflex  is  absent.  He  considers 
himself  well,  and  dates  the  commencement  of  returning  strength  from  the 
time  when  he  began  to  rub  his  limbs  with  whiskey. 

The  progressive  development  of  muscular  weakness,  unattended  by 
febrile  symptoms,  but  accompanied  by  diminution  of  the  size  of  the  limbs, 
by  abolition  of  the  patellar  tendon  reflex,  and  by  sensations  of  numbness, 
yet  without  loss  of  tactile  sensation,  and  without  interference  with  the 
function  of  either  rectum  or  bladder,  renders  the  diagnosis  clear  and  in- 
disputable. 

The  history  of  the  case  seems  to  demonstrate  the  futility  of  indifferent 
treatment,  the  injurious  effect  of  unwise  and  inappropriate  treatment,  and 
the  beneficial  results  of  a  carefully  selected  and  judicious  plan  of  treatment. 
The  patient  continued  to  grow  worse  while  he  was  taking  a  laxative  with 
a  bitter  tonic,  and  the  symptoms  increased  even  more  rapidly  under  the 
use  of  the  bromide  of  sodium  and  tincture  of  belladonna.  But  when  these 
remedies  were  discontinued,  when  rest  was  enforced  by  muscular  weak- 
ness, counter-irritation  was  applied  over  the  spine,  stimulating  frictions 
were  employed  upon  the  limbs,  and  ergot  and  iodide  of  potassium  were 
administered  internally,  improvement  was  observed  at  once,  and  continued 
until  the  patient  was  able  to  resume  his  work.  It  is  also  interesting  to 
note  that  the  diagnosis  was  made,  and  the  treatment  successfully  carried 
out  without  the  aid  of  electricity. 

When  we  recall  how  carefully  the  symptomatology  and  pathology  of  this 
disease  have  been  studied,  it  is  surprising  that  so  little  has  been  established 
as  to  the  comparative  value  of  the  various  remedies  which  have  been  em- 
ployed in  the  treatment  of  the  disease.  One  might  easily  be  led,  by  some 
of  the  recent  reports  of  cases,  to  suppose  that  treatment  was  a  matter  of 
secondary  importance,  and  that,  on  the  other  hand,  the  minute  observa- 
tion of  symptoms  and  electrical  reactions  was  alone  worthy  of  attention 


142 


Eliot,  Poliomyelitis  Anterior  in  Adults. 


[Jan. 


and  record.  A  large  proportion  of  the  reports  of  cases  which  have  been 
published  contain  little  or  no  information  concerning  the  details  of  treat- 
ment, and  in  many  others  the  multiplicity  of  drugs  prescribed  renders  any 
reliable  conclusions  in  regard  to  the  effect  of  each  almost  impossible. 
Even  Seguin,  in  his  elaborate  work,  while  discussing  the  treatment, 
abandons  the  analytical  method,  which  led  to  positive  conclusions  in  re- 
gard to  symptomatology  and  prognosis;  consequently  the  chapter  on  the 
former  subject  is  less  striking  than  the  others,  because  its  logic  is  less 
apparent. 

A  great  variety  of  drugs  has  been  used  and  recommended.  Bromide 
of  potassium,  belladonna,  strychnia,  ergot,  and  iodide  of  potassium  have 
been  most  often  employed,  and  most  praised.  Counter-irritation,  baths, 
rubbing  and  exercise,  and  electricity  are  also  included  as  important  ele- 
ments in  most  plans  of  treatment. 

The  bromide  of  potassium,  administered  with  ergot,  is  recommended  by 
Dr.  Sinkler.  Of  sixty  cases  (including  the  forty -five  collected  by  Seguin), 
whose  histories  have  come  to  my  notice,  the  bromides  were  used  in  three. 
Dr.  Sinkler  gave,  for  eight  days,  to  a  case  of  one  week's  duration,  ten  grain 
doses  of  bromide  of  potassium,  with  half  drachm  doses  of  wine  of  ergot.  At 
first  the  paralysis  increased,  but  after  three  or  four  days  there  was  improve- 
ment in  all  the  muscles,  and  complete  recovery  finally  resulted  under  the 
use  of  strychnia  and  faradism.  A  patient  of  Dr.  Hammond,  who  for 
several  months  had  had  gradually  increasing  paralysis,  took  bromide  of 
potassium  in  fifteen  grain  doses  with  the  iodide  of  potassium  and  ergot. 
Here  also  at  first  the  paralysis  increased,  but  subsequently  improvement 
commenced,  and,  electricity  being  also  employed,  continued  for  two  or 
three  months,  when  a  relapse  occurred.  On  this  occasion  iodide  of  potas- 
sium, ergot,  hypodermic  injections  of  strychnia,  and  faradism  were  used 
with  considerable  benefit.  In  my  own  case,  as  already  mentioned,  the 
bromide  of  sodium  was  given  with  tincture  of  belladonna,  for  a  week,  at 
the  beginning  of  the  second  month  of  the  disease,  and  during  that  period 
the  symptoms  rapidly  increased.  The  evidence  in  regard  to  the  value  of 
the  bromides  in  this  disease  is,  therefore,  entirely  inconclusive ;  for, 
although  it  might  be  urged  that,  in  the  first  two  cases,  bromide  and  ergot 
produced  a  beneficial  effect,  it  will  be  shown  later  on  that  equally,  and 
perhaps  more  favorable  results  follow  the  use  of  ergot  without  the  bro- 
mide. On  the  other  hand,  it  would  be  hardly  fair  to  attribute  the  appa- 
rently unfavorable  result  in  the  latter  case  to  the  bromide,  for  it  may  have 
been  due,  in  part  at  least,  to  the  belladonna,  to  whose  action  the  patient 
seemed  peculiarly  susceptible,  and  which  was  given  in  such  doses  as  to 
produce  physiological  effects. 

Belladonna,  however,  has  received  the  indorsement  of  Dr.  Seguin  as  a 
remedy  useful  in  this  disease.  Two  cases,  beside  my  own,  have  been  re- 
ported in  which  it  was  used.    Soulier,  quoted  by  Seguin,  gave  the  extract 


1885.] 


Eliot,  Poliomyelitis  Anterior  in  Adults. 


143 


of  belladonna,  with  iodide  of  potassium,  to  a  man  of  fifty-seven  years,  who 
had  been  ill  about  two  weeks.  At  the  same  time  the  actual  cautery  was 
repeatedly  applied  to  the  spinal  region.  Recovery  followed.  In  a  case  which 
Dr.  Seguin  saw  with  Dr.  T.  A.  McBride,  a  man  of  twenty-eight  years  was 
severely  dry-cupped  and  took  large  doses  of  belladonna  and  ergot.  Im- 
provement soon  commenced,  and  complete  recovery  followed.  Here  again 
the  facts  are  insufficient  to  warrant  any  positive  conclusion.  In  both  cases 
the  details  of  treatment  are  incompletely  stated,  and  moreover,  other  reme- 
dies, viz.,  counter-irritation  and  ergot,  were  used,  whose  value  is  much 
less  questionable.  In  my  own  case,  in  which  belladonna  was  used  with 
bromide  of  sodium,  and  pushed  to  the  production  of  physiological  effects 
with  an  unfavorable  result,  it  is  possible  that  the  bromide  alone  might 
have  proved  innocuous.  Under  the  existing  uncertainty  in  regard  to  their 
therapeutic  value,  it  would  certainly  be  wise  to  be  extremely  cautious  in 
the  use  of  either  drug. 

Concerning  the  iodide  of  potassium,  the  evidence  is  more  extensive. 
This  drug  has  formed  a  part  of  the  treatment  in  eleven  cases.  These  may 
be  divided  for  convenience  of  analysis  into  two  groups,  according  as  the 
remedy  was  employed  in  the  early  weeks  of  the  disease,  or  after  several 
months.  In  the  case  of  Dr.  Geddings,  reported  by  Seguin,  it  is  stated 
that  the  iodide  disagreed  after  a  few  doses.  In  a  case  which  came  under 
the  observation  of  Erb,  two  months  after  the  first  symptoms  appeared, 
iodide  of  potassium  was  administered  internally,  and  dry  cups  and  cold 
compresses  were  applied  externally.  The  patient  soon  commenced  to 
improve,  and  ultimately  nearly  recovered.  In  one  of  Charcot's  cases, 
quoted  by  Seguin,  great  improvement  resulted  in  three  months  under  the 
use  of  iodide  of  potassium  internally  and  moxas  to  the  spine.  Soulier's 
case  has  already  been  mentioned,  in  which  the  use  of  iodide  of  potash  with 
belladonna  and  the  actual  cautery,  commenced  at  the  end  of  three  weeks, 
resulted  in  complete  recovery  at  the  end  of  three  months.  Dr.  Hammond 
reports  the  case  of  a  man  of  thirty-five  years,  who,  on  the  fourth  day  of  the 
disease,  commenced  to  take  iodide  of  potassium  and  ergot.  The  paralysis 
increased  up  to  the  seventh  day,  but  improvement  commenced  on  the 
ninth  day.  Afterwards  electricity  was  employed,  and  at  the  end  of  a  year 
no  weakness  remained.  In  one  of  the  cases  reported  by  Dr.  Sinkler,  the 
patient,  a  man  twenty-three  years  old,  on  the  fourth  day  Avas  directed  to 
take  iodide  of  potassium  and  quinia.  The  paralysis  steadily  increased  for 
five  days,  when  the  treatment  was  changed.  In  my  own  case  the  iodide 
was  used  in  connection  with  ergot,  counter-irritation,  and  rubbing  of  the 
limbs,  commencing  at  about  the  sixth  week,  and  with  an  immediately 
favorable  result.  In  recent  cases,  therefore,  it  appears  that  iodide  of  potas- 
sium has  proved  of  little  value,  except  when  employed  with  ergot  or 
counter-irritation,  or  both. 


144 


Eliot,  Poliomyelitis  Anterior  in  Adults. 


[Jan. 


Of  the  cases  of  longer  standing,  one  reported  by  Hammond  has  already 
been  referred  to,  in  which  after  several  months  iodide  of  potassium  was 
used  with  ergot  and  other  drugs  and  electricity,  with  favorable  results, 
both  in  the  original  attack  and  in  a  relapse.  In  the  fatal  case  of  a  syphi- 
litic woman  twenty-six  years  old,  reported  by  Dejerine  and  quoted  by 
Seguin,  the  use  of  iodide  of  potassium  was  commenced  at  the  end  of  three 
months  and  continued  for  five  weeks,  during  which  time  there  was  slight 
improvement.  Six  weeks  later  the  paralysis  extended  to  the  upper  ex- 
tremities, and  after  seven  weeks  the  patient  died.  In  a  patient  whom 
Dr.  Sinkler  saw  after  six  months  the  iodide  was  used  in  connection  with 
massage,  faradism,  strychnia,  and  codeia,  and  the  patient  improved.  In 
another  case,  which  the  same  gentleman  treated  after  one  and  a  half  years, 
the  drug  was  employed  at  the  same  time  with  massage  and  faradism. 
This  patient  also  improved.  In  cases  of  long  standing,  therefore,  iodide 
of  potassium  does  not  seem  to  have  proved  efficacious  except  when  elec- 
tricity has  been  used  simultaneously  ;  nor,  on  the  other  hand,  does  it  seem 
to  have  prevented  the  improvement,  or  even  complete  recovery,  which 
ordinarily  attends  the  use  of  electricity. 

Strychnia  has  been  given  in  some  cases.  In  one  reported  by  Seguin  a 
second  attack  occurred  in  a  man  aged  twenty -one,  who  was  taking  strych- 
nia for  the  relief  of  the  weakness  which  remained  from  a  former  attack. 
Another  patient,  whom  Hammond  and  Seguin  both  saw,  "  took  strychnia 
for  a  time  without  any  effect,  good  or  bad."  In  several  other  cases,  in 
which  it  was  used,  recovery  was  slow.  While,  therefore,  it  may  not  always 
do  harm  it  may  be  said  that  its  utility  in  this  affection  is  not  well  estab- 
lished. On  the  contrary,  there  is  reason  to  believe  that  sometimes  it  may 
do  positive  injury.    Consequently  it  should  be  avoided. 

Ergot  has  been  considerably  used  and  highly  commended.  In  the  case, 
already  mentioned,  in  which  Dr.  Sinkler  employed  it  in  connection  with 
bromide  of  potassium  and  the  external  application  of  a  stimulating  lini- 
ment, some  muscles  improved  and  others  did  not.  When,  however,  elec- 
tricity was  added  to  the  treatment  all  improved.  The  improvement  was 
not  interrupted  by  the  substitution  of  strychnia  for  the  other  drugs,  elec- 
tricity being  continued,  nor  later  by  the  exchange  of  strychnia  for  ergot. 
Finally  complete  recovery  resulted.  Dr.  Geddings  took  ergot  for  a  time 
with  no  appreciable  effect,  but  subsequently  when  counter-irritation  aud 
galvanism  were  used  at  the  same  time,  complete  recovery  followed.  Dr. 
McBride's  patient  was  severely  dry-cupped,  and  took  large  doses  of  ergot 
and  belladonna.  In  a  few  months  all  paralytic  symptoms  passed  away. 
Dr.  Hammond  used  the  drug  in  three  cases.  One  patient,  a  woman  of 
twenty-seven  years,  having  already  improved  somewhat,  after  two  months 
was  treated  with  ergot  and  electricity,  and  completely  recovered.  The  two 
other  cases  were  mentioned  in  speaking  of  iodide  of  potassium.    In  one  of 


1885.] 


Eliot,  Poliomyelitis  Anterior  in  Adults. 


145 


these  ergot  was  given  with  the  iodide,  and  after  there  was  some  return  of 
motility  electricity  was  used  until  complete  recovery  resulted.  In  the 
other,  ergot  was  given  with  the  iodide  and  bromide  of  potassium,  and 
after  improvement  commenced  electricity  was  employed  in  addition. 
After  several  weeks  a  relapse  occurred  which  was  treated  with  ergot  and 
the  iodide  of  potassium,  with  hypodermic  injections  of  strychnia  and  elec- 
tricity. The  patient  improved  greatly,  although  some  atrophy  of  the 
muscles  persisted.  In  my  own  case,  under  the  use  of  ergot  and  iodide  of 
potassium,  with  counter-irritation  and  rubbing  of  the  limbs,  the  patient 
improved  rapidly.  There  is,  therefore,  considerable  reason  for  believing 
that  ergot  is  useful  in  this  disease.  It  seems  to  have  done  no  harm,  but, 
on  the  contrary,  to  have  been  beneficial  in  all  the  cases  in  which  it  was 
used.  There  was,  moreover,  no  other  element  of  treatment  common  to  the 
cases  enumerated,  while,  on  the  other  hand,  in  some  of  them  it  was  used 
with  drugs,  whose  value  is,  to  say  the  least,  questionable. 

Naturally,  since  most  of  the  cases  reported  were  treated  by  specialists 
in  nervous  diseases,  electricity  has  been  employed  more  frequently  than 
anything  else.  It  has  been  used  early  and  late,  and  in  the  forms  of  both 
galvanism  and  faradism,  generally  with  favorable  effects.  The  only 
apparent  exception  is  the  case  of  Dr.  Lincoln,  in  which  the  faradic  cur- 
rent was  applied  from  the  fifth  to  the  twenty -first  day,  during  which  time 
the  paralysis  increased.  The  galvanic  current  was  then  tried  and  con- 
tinued until  recovery,  which  commenced  about  the  twenty-fifth  day. 
This  patient  also  took  strychnia.  More  frequently  electricity  has  been 
first  used  after  the  paralysis  has  ceased  to  increase,  and  then  it  has  always 
seemed  to  promote  recovery.  Often  in  old  cases  great  benefit  has  resulted 
from  the  use  of  the  faradic  current,  when  it  is  capable  of  inducing  con- 
tractions in  the  affected  muscles.  Otherwise  galvanism  is  more  effica- 
cious. 

Counter-irritation  has  been  employed  in  many  cases  which  have  resulted 
favorably  and  in  some  immediate  improvement  has  followed. 

Massage  of  the  affected  muscles,  and  rubbing  of  the  extremities  in- 
volved, have  also  been  employed,  with  apparent  advantage,  in  many  of 
the  cases  which  recovered. 

Finally,  it  must  be  mentioned  that,  while  a  few  cases  have  not  proved 
amenable  to  treatment,  some,  on  the  contrary,  have  entirely  recovered, 
or  markedly  improved,  without  any  treatment. 

The  following  conclusions  are  drawn  from  a  study  of  the  results  of 
various  plans  of  treatment  as  reported  by  different  observers. 

First.  Counter-irritation  and  ergot  should  be  employed  early  in  every 
case. 

Second.  Massage  and  electricity  should  be  used  as  soon  as  there  is  any 
evidence  of  improvement. 

No.  CLXXVII  Jan.  1885.  10 


146 


Reichert,  Regeneration  of  the  Vagus. 


[Jan. 


Third.  Little,  if  any,  effect  can  be  expected  from  iodide  of  potassium. 
Fourth.  Belladonna  and  the  bromides  should  be  used  only  with  extreme 
caution. 

Fifth.  Strychnia  should  be  entirely  avoided. 

The  value  of  these  conclusions  is  greatly  impaired  because  they  are 
based  on  a  small  number  of  cases,  and  because  the  effect  of  any  particular 
remedy  is  obscured  by  the  possible  effects  of  others  which  were  used  at 
the  same  time.  Consequently  it  is  exceedingly  desirable  that  new  cases 
should  be  reported  as  they  occur,  and  that  in  all  reports  the  details  of 
treatment,  whether  successful  or  unsuccessful,  should  be  stated  more  de- 
finitely than  has  hitherto  been  customary. 

September  25,  1884. 


Article  XII. 

Observations  on  the  Regeneration  of  the  Vagus  and  Hypoglossal 
Nerves.  By  Edward  T.  Reichert,  M.D.,  Demonstrator  of  Experimental 
Physiology  and  Experimental  Therapeutics  in  the  University  of  Pennsylvania. 

Since  the  time  of  Fontana  the  subject  of  the  regeneration  of  cut  nerves 
has  been  one  of  great  interest  and  importance,  and  some  experimental 
work  has  been  done  with  more  or  less  success. 

At  the  present  time  there  seems  to  be  no  difference  in  opinion  as  to  the 
fact  that  fibres  of  the  cut  ends  of  nerves  will  unite  with  similar  fibres  ; 
that  sensory  fibres  will  reunite  wTith  sensory  fibres,  and  motor  fibres  with 
motor  fibres,  and  that  as  a  result  the  regenerated  sensory  nerve  will  still 
convey  sensory  impulses  and  the  regenerated  motor  nerve  motor  impulses. 
In  the  case,  however,  of  the  regeneration  of  sensory  with  motor  fibres 
there  yet  exists  considerable  uncertainty.  The  well-known  experiments 
of  Bidder,  on  the  lingual  and  hypoglossal,  are  without  value  in  proving 
that  sensory  and  motor  fibres  can  regenerate  because  he  neglected  to  so 
prepare  the  cut  ends  of  the  nerves  as  to  prevent  reunion  of  similar  fibres, 
and  as  a  consequence,  in  most  of  his  experiments,  the  four  cut  ends  of  the 
nerves  were  found  imbedded  together  in  a  mass  of  inflammatory  matter, 
so  that  it  was  impossible  to  tell  in  what  manner  the  fibres  had  reunited; 
while  in  others,  the  lingual  had  reunited  with  its  mate  and  the  hypoglossal 
with  its  mate,  but  never  was  it  clear  that  the  fibres  of  the  lingual  and 
hypoglossal  had  become  united.  Both  Vulpian  and  Rosenthal  have  thought 
that  they  were  successful  in  uniting  motor  fibres  of  the  hypoglossal  with 
sensory  fibres  in  the  lingual,  but  even  these  investigators  no  longer  insist 
that  there  was  a  reunion  of  sensory  with  motor  fibres.  Nor  have  the  expe- 
riments of  Vulpian  and  Phillipeaux.been  attended  with  any  better  success. 
They  made  two  experiments  on  young  dogs,  in  which  they  joined  the  cen- 


1885.] 


Reichert,  Regeneration  of  the  Vagus. 


147 


tral  end  of  the  .vagus  with  the  peripheral  end  of  the  hypoglossal.  The 
animals  were  examined  after  death  two  months  succeeding  the  operation, 
but  not  during  life.  Upon  examination  of  the  sutured  nerve  they  found 
that  the  ends  of  the  two  nerves  were  united  by  filaments  of  connective 
tissue  (only  one  filament  in  one  dog),  which  in  their  opinion  contained  no 
nervous  matter.  They  did  not  find  any  properly  regenerated  fibres  in  the 
hypoglossal  trunk,  only  thin  fibres,  like  newly-formed  nerve-fibres,  in 
which  the  medullary  sheath  was  scarcely  developed,  and  they  regard  it  as 
a  regeneration  independent  of  reunion. 

Notwithstanding  the  universal  failure  to  unite  sensory  with  motor  fibres, 
there  are  a  number  of  German  physiologists  who  still  believe  that  such 
regeneration  can  occur.  SchifF  has,  however,  made  a  long  series  of  expe- 
riments, which  are  not  yet  quite  completed,  in  which  he  has  fully  satisfied 
himself  that  it  is  impossible  to  unite  sensory  with  motor  fibres.  A  speci- 
men from  this  series  was  exhibited  by  him  at  a  meeting  of  the  Society  of 
German  Naturalists  some  years  ago,  in  which  it  seemed  from  the  appear- 
ances of  the  nerve  trunk  that  the  hypoglossal  and  lingual  had  actually 
become  united,  because  the  restoration  of  the  trunk  at  the  point  of  union 
of  the  two  nerves  had  been  so  accurately  performed  during  the  healing 
process  that  there  was  scarcely  an  appreciable  enlargement,  but  micro- 
scopical examinations  showed  that  all  the  internal  fibres  of  the  lingual 
going  to  the  mucous  membrane  were  degenerated.  He,  however,  did  find 
a  few  regenerated  fibres  which  proved  to  be  vaso-motor.  In  not  a  single 
instance  has  he  been  satisfied  that  sensory  and  motor  fibres  will  unite. 

The  experiments  recorded  in  the  present  paper  were  made  to  learn  it 
the  fibres  of  nerves  of  entirely  different  origin  and  function  would  unite, 
and  if  regeneration  should  occur  to  know  the  form  of  the  return  of  func- 
tion, or,  in  other  words,  to  know  if  a  motor  nerve  was  capable  of  convey- 
ing impulses  peculiar  to  another  motor  nerve. 

The  importance  of  the  latter  part  of  this  statement  can  better  be  appre- 
ciated when  we  consider  the  results  of  some  recent  experiments  published 
by  a  Russian  (I  have  not  seen  the  original  paper)  on  the  regeneration 
of  the  nerves  of  the  extremities.  These  experiments  were  made  on 
various  animals  in  which  different  trunks  were  united,  and  it  is  stated  that 
after  regeneration  of  the  nerves  the  animals  were  still  able  to  perform • 
normal  coordinated  movements.  This  result  seems  so  incredible  that  there 
is  some  strong  probability  of  faulty  observation,  for  it  is  obvious  that  if 
such  a  condition  should  exist  the  centre  must  have  undergone  such  altera- 
tion in  function  that  impulses  having  an  entirely  different  object  are  now 
transmitted  by  the  peripheral  end  of  the  nerve  to  the  muscles — as,  for 
example,  the  centre,  which  before  generated  and  transmitted  impulses  at 
a  certain  time  to  extensor  muscles,  must  now  supply  flexor  muscles,  and 
as  a  consequence  in  order  that  there  may  be  coordinated  movements  must 
supply  impulses  at  a  time  directly  opposite  to  the  normal.    Is  it  possible  ? 


148  Reichert,  Regeneration  of  the  Vagus.  [Jan. 

In  the  present  experiments  the  vagus  and  hypoglossal  were  selected  as 
being  nerves  of  distinct  origin  and  function,  and  which,  in  case  of  regene- 
ration, would  probably  afford  the  best  facilities  for  accurate  observation. 
Five  dogs  were  accordingly  prepared  during  the  last  week  of  February  by 
Prof.  Schiff,  in  which  he  cut  the  hypoglossal  on  one  side  close  to  its  exit 
from  the  cranium  and  the  vagus  at  the  thyroid.  The  peripheral  end  of 
the  vagus  was  then  cut  off  as  low  in  the  neck  as  the  wound  permitted. 
The  sections  of  the  nerves  were  all  made  with  a  razor  or  very  sharp  scissors, 
and  the  peripheral  end  of  the  hypoglossal  was  sutured  to  the  central  end 
of  the  vagus  in  each  case  by  means  of  a  stitch  of  raw  silk  from  the  cocoon 
run  through  the  neurilemma  with  a  very  small  needle.  In  some  cases  the 
loop  of  nerve  was  so  long  that  a  small  portion  of  one  or  both  nerves  was 
cut  off. 

The  usual  atrophy  of  the  side  of  the  tongue  and  tremor  which  occur 
after  section  of  the  hypoglossal  were  observed  in  all  of  the  dogs,  but  from 
the  eleventh  to  the  sixteenth  week  after  the  operation,  Prof.  Schiff  noticed 
localized  areas  of  contraction,  in  which  contraction  was  distinct  from  any 
general  movements  of  the  tongue.  The  degree  of  contraction  in  these 
areas  gradually  increased  until  the  middle  of  the  sixth  month  following 
the  operation,  when  I  examined  the  dogs  and  made  the  observations  re- 
corded in  this  paper.  Simple  section  of  the  hypoglossal  was  made  in 
other  dogs  at  the  same  time,  in  February,  in  order  to  compare  the  two 
sets  ;  but  never  in  these  dogs  were  any  of  the  localized  areas  of  contrac- 
tion observed,  as  were  seen  in  the  dogs  with  the  sutured  vagus  and  hypo- 
glossal. At  the  middle  of  the  sixth  month  following  the  operation  the 
following  notes  were  made  : — 

In  all  of  the  dogs  there  is  atrophy  of  the  side  of  the  tongue  correspond- 
ing to  the  operation  equal  to  a  loss  of  about  one-fourth  of  the  normal  size. 
The  anterior  third  of  the  atrophied  side  is  marked  by  numerous  shallow 
fissures,  having,  for  the  most  part,  a  direction  outwards  and  forwards, 
somewhat  radiating,  and  gradually  fading  away  towards  the  edge  of  the 
tongue.  These  more  prominent  fissures  have  between  them,  and  are  fre- 
quently intercepted  by,  smaller  fissures,  giving  the  surface  of  the  tongue 
somewhat  the  appearance  of  the  surface  of  the  cerebral  convolutions.  The 
posterior  two-thirds  are  marked  by  numerous  pit-like  depressions,  some  of 
which  are  deeper  than  others,  and  which  are  scattered  with  much  uni- 
formity. The  appearances  of  this  side  of  the  tongue  are  quite  character- 
istic when  compared  with  the  general  rounded,  smooth,  and  regular  form 
of  the  normal  side.  When  the  tongue  is  protruded,  it  is  towards  the  dis- 
eased side,  and  when  drawn  in,  it  is  towards  the  normal  side.  The  dis- 
eased side  is  altogether  without  the  movements  produced  by  the  active 
hypoglossus.  Over  the  whole  of  the  surface  of  the  operated  side  of  the 
tongue,  but  more  particularly  along  the  edge  of  the  anterior  third  and  the 
whole  of  the  posterior  two-thirds,  is  seen  a  general  tremor  of  a  decidedly 


1885.] 


Reichert,  Regeneration  of  the  Vagus. 


149 


metastatic  character.  This  tremor  flits  from  point  to  point,  but  there  are 
always  so  many  points  in  tremor  that  the  surface  of  the  side  of  the  tongue 
has  a  general  tremulousness,  and  there  do  not  appear  to  be  any  distinct 
isolated  points  which  are  entirely  free  from  tremor  for  any  more  than  a  few 
moments  at  a  time  at  most.  The  tremor  is  generally  quite  superficial  in 
character,  but  at  times  is  considerably  exaggerated  in  depth,  and  has  a 
character  not  unlike  decided,  but  rapidly  repeated  muscular  contractions. 
The  tremor  is  greatly  modified  by  various  circumstances,  as,  for  instance, 
it  is  increased  by  excitement,  movements  of  swallowing,  and  vomiting. 

Besides  the  tremor  other  abnormal  contractions  are  observed  which  are 
quite  extraordinary  in  character.  These  are  seen  in  certain  isolated  areas 
which  are  clearly  outlined,  and  are  of  a  very  distinct,  slow,  rhythmical 
character  very  different  from  any  general  movements  of  the  side  of  the 
tongue.  These  contractions  are  seen  in  all  of  the  dogs,  and  by  placing  the 
hand  upon  the  chest  and  observing  the  contractions  in  these  areas  an  un- 
mistakable relation  is  apparent  between  the  rhythmical  contractions  in 
the  tongue  and  the  movements  of  respiration.  These  movements,  in  both 
cases,  were  recorded  graphically  in  two  ways — first,  by  recording  the 
respiratory  movements  by  means  of  a  Marey's  pneumograph  connected 
with  a  recording  tambour  writing  on  a  revolving  drum,  and  simultaneously 
recording  the  movements  in  any  one  selected  area  in  the  tongue  by  mak- 
ing and  breaking  of  the  current  with  a  telegraph  key  which  was  connected 
with  a  chronograph,  which  also  recorded  on  the  drum  on  the  same  vertical 
line  as  the  lever  of  the  tambour  ;  second,  by  using  the  pneumograph  and 
tambour  as  above  and  recording  the  contraction  in  the  side  of  the  tongue 
by  fixing  to  the  edge  of  the  operated  side  of  the  tongue  a  Kronecker's 
muscle  forceps  which  was  connected  with  the  lever  of  a  tambour,  which 
tambour  in  turn  was  connected  with  a  recording  tambour  marking  on  the 
drum  below  the  tambour  recording  the  thoracic  movements.  In  the  first 
method  of  recording  the  telegraph  key  was  pressed  upon  by  the  finger  at 
the  commencement  of  contraction  causing  elevation  of  the  pen  of  the  chro- 
nograph and  released  at  the  cessation,  causing  depression  of  the  pen.  In 
the  second  method  records  were  made  of  both  sides  of  the  tongue  for  com- 
parison in  order  to  obviate  any  fallacy  likely  to  arise  from  general  move- 
ments of  the  tongue. 

As  the  areas  of  contraction  as  well  as  certain  characters  of  the  contrac- 
tion vary  in  the  different  dogs  it  will  be  necessary  to  record  the  observations 
in  the  different  animals  seriatim. 

In  dog  No.  1,  two  distinct  areas  of  contraction  are  seen,  one  on  the 
edge  of  the  tongue  at  the  junction  of  the  anterior  and  middle  thirds,  and 
extending  inwards  for  about  5  mm  ;  the  second  an  oblong  area  in  the  pos- 
terior internal  part  of  the  middle  third,  and  about  1  cm.  in  length  by  4 
mm.  in  breadth.  When  contraction  occurs  in  the  first  area  the  edge  of  the 
tongue  is  drawn  inwards,  and  when  at  the  latter  point  the  surface  of  the 


150 


Reichert,  Regeneration  of  the  Vagus. 


[Jan. 


tongue  is  decidedly  depressed.  Both  of  these  movements  occur  simul- 
taneously with  expiration.    (See  Fig.  1  and  Tracings  1  and  2.) 


In  dog  No.  2,  five  distinct  areas  are  observed,  one  of  which  is  situated 
at  the  junction  of  the  anterior  and  middle  thirds,  and  one  at  the  junction 
of  the  middle  and  posterior  thirds,  each  being  a  little  over  a  centimetre  in 
length  by  3  or  4  mm.  in  diameter  and  situated  a  little  within  the  middle 
line.  A  third  area  is  situated  on  the  edge  of  the  tongue  about  5  mm. 
anterior  to  the  point  of  junction  of  the  anterior  and  middle  thirds.  At 
these  three  points  contraction  occurs  consentaneous  with  expiration.  One 
of  the  remaining  areas  is  situated  on  the  edge  of  the  tongue  in  the  middle 
third,  and  the  other  on  the  edge  of  the  tongue  about  1  cm.  anterior  to  the 
junction  of  the  anterior  and  middle  thirds.  At  these  points  (marked  x) 
contraction  is  simultaneous  with  inspiration.  (See  Fig.  2,  Tracings  3 
and  4.) 

In  dog  No.  3,  one  large  area  of  contraction  was  observed  situated  in 
the  middle  and  posterior  thirds  about  1.5  cm.  long  by  5  mm.  wide ;  also, 
two  small  areas  at  the  junction  of  the  anterior  and  middle  thirds  situated 
on  the  edge  of  the  tongue  about  5  mm.  apart.  At  all  these  points  con- 
traction was  in  relation  with  expiration.  In  areas  marked  x  contraction 
is  observed  in  deep  expiration.    (See  Fig.  3,  Tracing  5.) 

In  dog  No.  4,  in  the  middle  and  posterior  thirds  of  the  tongue,  are  three 
lineal  areas,  two  of  which  are  parallel  with  the  raphe,  and  situated  about 
3  mm.  from  it,  and  a  third  lineal  area  of  small  extent  in  the  posterior 
part  of  the  posterior  third  running  backwards  and  outwards  {Fig.  4). 
The  contrations  in  these  areas  are  quite  distinct  in  their  character  from 
those  occurring  in  the  other  dogs,  for  instead  of  being  a  single  tonic  con- 
traction there  are  successive  contractions  rapidly  following  each  other 


Fig.  1. 


Fig.  2. 


1885.] 


Reichert,  Regeneration  of  the  Vagus. 


151 


such  as  are  observed  when  a  muscle  is  irritated  by  ten  or  twelve  induction 
shocks  per  second.  In  ordinary  respiration  there  are  but  two  contractions, 
but  in  deep  breathing  the  series  may  consist  of  three  or  four.  These  con- 
Fig.  4. 


tractions  always  occur  with  inspiration.    In  deep  inspiration  five  other 
areas  are  observed  (marked  x),  one  of  some  dimension  in  the  posterior 
third,  two  in  the  middle  third,  and  two  at  the  junction  of  the  anterior 
third — one  on  the  edge  of  the  tongue  and 
one  near  the  middle  of  the  line,  all  of  small 
dimensions.    (  Tracing  6.) 

In  dog  No.  5  are  seen  five  areas  in  which 
contraction  occurs  during  expiration.  One 
is  situated  in  the  posterior  part  of  the  pos- 
terior third  and  four  in  the  middle  third, 
one  near  the  edge  of  the  tongue,  5  mm.  from 
the  junction  of  the  posterior  third,  one  on 
the  edge  near  the  middle,  one  near  the  edge 
at  the  junction  with  the  anterior  third,  and 
one  near  the  middle  close  by  the  raphe. 
The  five  are  all  of  small  dimensions. 
{Fig.  5,  Tracing  7.)  There  are  also  two 
small  areas,  one  in  the  middle  third  touch- 
ing the  junction  with  the  posterior  third 
and  near  the  raphe,  and  the  second  near 
the  raphe  at  the  junction  of  the  middle 

and  anterior  thirds  (marked  x),  in  which  contraction  occurs  simultaneous 
with  inspiration.    (  Tracing  8.) 

In  all  the  dogs  the  respiratory  movements  in  the  tongue  were  greatly 


152 


Reich ert,  Regeneration  of  the  Vagus. 


[Jan. 


modified  by  various  circumstances.  In  quiet  breathing  the  contractions 
were  shallow,  and  in  dog  No.  4  were  scarcely  to  be  seen.  In  deep 
breathing  they  were  greatly  exaggerated,  while  in  raoid,  panting  breathing, 
such  as  is  caused  by  running  the  dog  in  the  sun  in  hot  weather,  they  are 
diminished  or  altogether  lost.  Coughing  always  increases  the  degree  of 
contraction  in  the  expiratory  areas. 

After  section  of  the  normal  vagus  the  respiratory  movements  became 
slow  and  labored,  and  all  the  characteristics  immediately  following  simul- 
taneous section  of  both  vagi  were  present.  The  respiratory  contractions 
were  enormously  exaggerated,  especially  in  the  inspiratory  areas,  and 
many  more  small  areas  of  contraction  were  noted  which  before  were  un- 
appreciable.  When  the  central  end  of  the  cut  vagus  was  irritated  by  a 
rapidly  interrupted  current  the  frequency  of  the  respiratory  contractions 
were  increased  corresponding  to  the  increased  frequency  of  the  thoracic 
movements.  {Tracing  9.)  Stimulation  of  the  superior  laryngeal  causes 
slowing  of  the  respiratory  contractions  in  the  tongue  and  thorax.  (  Trac- 
ing 10.) 

When  the  vagus  of  the  regenerated  side  was  cut  near  its  exit  from  the 
cranium  the  rhythmical  movements  on  the  side  of  the  tongue  immediately 
cease,  and  the  side  of  the  tongue  is  without  any  movements  peculiar  to 
the  muscles  of  that  side  of  the  tongue.  If  the  peripheral  end  of  the  cut 
vagus  is  irritated  by  a  rapidly  interrupted  current,  contraction  occurs  in 
the  side  of  the  tongue  at  the  areas  in  which  the  contractions  corresponding 
to  respiration  were  observed.  In  one  dog  the  peripheral  end  of  the  vagus 
was  not  excitable  by  even  a  maximal  current  although  the  trunk  of  the 
hypoglossal  to  which  it  was  united  was  excitable  to  a  very  moderate  cur- 
rent— a  condition  before  observed  by  physiologists  where  a  nerve  was  not 
excitable  by  electrical  stimulus  yet  functionally  capable.  When  the  same 
hypoglossal  trunk  was  electrically  excited  by  applying  the  electrodes  about 
1.5  cm.  from  the  point  of  union  with  the  vagus  not  only  was  contraction 
induced  in  the  respiratory  areas  in  the  side  of  the  tongue,  but  the  respira- 
tion was  increased  in  frequency  and  depth,  while  the  blood  pressure  was 
diminished  but  without  any  decided  effect  in  the  heart.  {Tracing  11.) 
With  a  stronger  current  the  respirations  were  greatly  increased  in  fre- 
quency, the  blood  pressure  lowered  to  a  greater  degree,  there  was  decided 
inhibition  of  the  heart,  and  immediately  after  the  cessation  of  the  irri- 
tation vomiting  ensued.  {Tracing  12.)  These  observations  were 
several  times  repeated  in  the  dog  and  always  with  the  same  result,  and 
from  them  we  must  infer  that  some  of  the  sensory  fibres  in  the  hypoglossal 
had  become  united  with  similar  fibres  in  the  vagus,  and  that  impulses 
generated  in  the  hypoglossal  were  conveyed  through  the  sensory  fibres  of 
the  vagus  the  same  as  normal  impulses  from  the  vagus  peripheries  and  with 
the  same  effects  on  the  nerve  centres.  Unfortunately  this  observation  was 
only  made  on  the  last  dog  killed. 

Besides  the  extraordinary  movements  above  described  others  were  noted 


1885.] 


Eeicheet,  Regeneration  of  the  Vagus. 


153 


of  a  not  less  interesting  character  nor  less  remarkable.  Thus  in  four  of  the 
dogs  very  peculiar  contractile  movements  were  observed  during  the  act  of 
swallowing.  In  order  to  observe  them  the  dog's  mouth  was  held  firmly 
open  and  water  was  injected  or  poured  into  the  back  of  the  mouth,  or 
pieces  of  bread  or  meat  pushed  back  to  the  pharynx  when  he  was  forced 
to  swallow.  When  swallowing  occurred  a  series  of  contractions  were  seen 
in  areas  in  the  posterior  and  middle  thirds  of  the  tongue  (shown  in  the 
diagrams  by  the  broken  lines)  which  were  characterized  by  distinct  con- 
tractions in  numerous  small  points,  the  contractions  occurring  in  sequence 
and  seemingly  running  into  each  other,  giving  the  whole  series  a  some- 
what vermicular  character.  In  this  play  of  movements  the  individual 
contractions  followed  each  other  so  rapidly  that  it  was  not  possible  to  map 
out  any  distinct  order  of  the  contractions  in  the  several  points.  These 
swallowing  movements  seemingly  occurred  during  the  passage  of  the 
food  down  the  oesophagus,  and  were  very  slight  in  degree  when  the 
animal  made  a  simple  swallowing  movement ;  they  were  more  distinct 
when  water  was  swallowed,  especially  so  if  the  quantity  was  large  ;  they 
were  very  marked  during  the  passage  of  meat  or  bread,  and  were  intensi- 
fied in  proportion  to  the  bolus.  In  dog  No.  2  no  swallowing  movements 
were  observed,  and  in  dog  No.  5  they  were  more  decided  than  in  the  others. 

A  similar  play  of  movements  was  also  observed  during  the  act  of 
vomiting  and  in  exactly  the  same  areas.  The  plan  pursued  in  studying 
the  vomiting  movement  was  to  feed  the  dog  on  pieces  of  bread  or  meat 
and  then  produce  vomiting  by  means  of  hypodermic  injections  of  apomor- 
phine.  For  a  few  minutes  preceding  emesis  distinct  movements  similar 
to  those  observed  during  swallowing  were  seen  and  which  were  due  to  the 
swallowing  of  air  or  saliva.  During  retching  there  was  a  decidedly  con- 
tracted condition  of  the  side  of  the  tongue  with  each  effort  at  expulsion, 
and  during  the  act  of  vomiting,  apparently  during  the  passage  of  the  food 
up  the  oesophagus,  the  play  of  movements  was  beautifully  marked,  and 
even  after  the  mass  of  the  contents  of  the  stomach  was  ejected  from  the 
mouth  the  movements  oftentimes  continued  for  a  few  moments,  and  were, 
no  doubt,  dependent  upon  continued  regurgitant  movements  in  the  oeso- 
phagus. In  dog  No.  2,  in  which  no  swallowing  movements  were  noted, 
no  vomiting  movements  were  observed,  and  in  dog  No.  5  both  the  swallow- 
ing and  vomiting  movements  were  very  decided.  The  vomiting  movements 
produced  by  mechanical  irritation  of  the  pharynx,  by  digitalis  or  atropine, 
did  not  possess  any  appreciable  difference  from  the  vomiting  produced  by 
apomorphine.  No  distinct  movement  corresponding  to  dilatation  or  con- 
traction of  the  oesophageal  sphincter  could  be  detected. 

The  dogs  were  also  repeatedly  examined  with  great  care  to  discover  con- 
tractile movements  in  the  tongue  which  might  be  consentaneous  with 
movements  of  the  heart,  but  only  in  two  dogs  (Nos.  3  and  5)  could  any 
connection  be  detected  and  even  in  them  not  with  any  degree  of  satisfac- 
tion.   In  both  of  these  dogs  there  were  several  points  along  the  edge  of 


154 


Reichert,  Regeneration  of  the  Vagus. 


[Jan. 


the  tongue,  in  the  anterior  and  middle  thirds,  at  which  contractions 
occurred  which  appeared  to  be  simultaneous  with  the  movements  of  the 
heart,  and  even  after  the  heart  beats  were  considerably  reduced  by  the  use 
of  liberal  doses  of  digitalis  the  connection  was  still  only  probable ;  but 
never  could  there  be  counted  together  more  than  three  or  four  contractions 
which  were  simultaneous  with  the  movements  of  the  heart  before  the  con- 
stant tremor  in  the  side  of  the  tongue  would  interfere  with  the  count. 
It  was  not,  therefore,  satisfactorily  determined  that  there  were  movements 
simultaneous  with  the  heart  beat. 

At  the  end  of  the  sixth  month  and  beginning  of  the  seventh  month 
after  the  operation  the  dogs  were  all  killed  (excepting  dog  No.  5,  which 
died  during  that  time  from  the  effects  of  digitaline),  and  observations  made 
on  them  such  as  were  already  recorded  in  connection  with  the  respiratory 
movements.  After  death  the  regenerated  nerves  were  carefully  exam- 
ined.   In — 

Dog  No.  1  Neither  the  hypoglossal  nor  vagus  were  at  all  wasted, 

when  compared  with  the  normal  nerves.  At  the  point  of  regeneration 
there  was  a  slight  fusiform  enlargement  about  2  mm.  greater  in  diameter 
than  the  nerve  trunks.  The  lengths  of  nerve  from  point  of  regeneration 
to  the  tongue,  5  cm. 

Dog  No.  2  The  hypoglossal  was  atrophied  to  about  one-half  of  its 

normal  size  and  the  vagus  but  little.  Where  the  vagus  and  hypoglossal 
were  united,  there  was  a,  small  oblong  thickening  about  1  cm.  long  and 
0.4  cm.  wide,  together  with  some  thickening  of  the  connective  tissues  about 
the  nerve.  The  length  of  the  hypoglossal  trunk  from  point  of  union 
7.5  cm. 

Dog  No.  3. — The  hypoglossal  was  wasted  about  one-third  of  its  normal 
size  and  the  vagus  slightly  so.  At  the  point  of  junction  of  the  two  nerves 
there  was  very  little  thickening.    Length  of  hypoglossal  trunk  4.5  cm. 

Dog  No.  4. — Neither  the  hypoglossal  nor  vagus  was  at  all  atrophied. 
Where  the  nerves  were  joined  there  was  a  triangular  thickening  the  angles 
of  which  being  formed  by  the  peripheral  ends  of  the  hypoglossal  and 
vagus  and  the  central  end  of  the  vagus.  The  thickening  was  about  1  cm. 
in  diameter.  The  length  of  the  hypoglossal  from  point  of  reunion 
5.5  cm. 

Dog  No.  5  The  hypoglossal  was  slightly  atrophied  and  the  vagus 

wasted  to  about  one-half  of  its  normal  size^  At  the  point  of  reunion  of 
the  two  nerves  there  was  a  round  flattened  enlargement  about  0.7  cm. 
in  diameter.    The  length  of  hypoglossal  nerve  5  cm. 

Microscopical  examination  of  the  hypoglossal  trunks  of  the  regenerated 
nerves  showed  that  they  contained  few  degenerated  fibres  and  large  num- 
bers of  small  fibres  having  little  medullary  sheath. 

From  the  above  observations  it  seems  obvious  that  the  motor  fibres  of 
the  vagus  in  all  of  the  five  dogs  operated  upon  had  actually  become  united 
to  similar  fibres  in  the  trunk  of  the  hypoglossal,  and  that  the  hypoglossal 


1885.] 


Reichert,  Regeneration  of  the  Vagus. 


155 


fibres  conveyed  impulses  which  were  peculiar  to  the  vagus  apparatus. 
Moreover,  that  in  at  least  one  clog  (the  others  not  being  examined  in  this 
way)  irritation  of  the  sensory  fibres  in  the  hypoglossal  trunk  gave  rise  to 
impulses  which  were  conveyed  by  the  sensory  fibres  of  the  vagus  to  the 
vagus  centres,  and  produced  effects  like  those  induced  by  excitation  of  the 
vagus  trunk,  thus  showing  in  both  instances  that  a  motor  or  sensory  nerve 
can  convey  impulses  peculiar  to  another  motor  or  sensory  nerve  of  entirely 
different  origin  and  function  ;  and  indicating  that  at  least  in  some  nerves 
the  effects  produced  by  impulses  from  the  periphery  are  not  dependent  upon 
any  peculiarity  of  impulses  due  to  physiological  peculiarities  of  the  peri- 
pheral sense-organs  or  nerves  through  which  the  impulses  are  conducted,  but 
upon  the  peculiar  physiological  properties  of  the  nerve  centres,  hence  we 
have  respiratory  movements,  etc.,  occurring  in  the  tongue  brought  about 
by  impulses  from  the  vagus  centres  through  the  hypoglossal  nerve,  and 
effects  on  the  respiration,  pulse,  pressure,  and  vomiting  centre,  through 
impressions  carried  to  the  vagus  centres  by  impulses  generated  in  the 
hypoglossal. 

Not  only  do  we  find  motor  fibres  of  distinct  origin  and  function  united, 
but  we  find  among  the  vagus  fibres  at  least  three  physiologically  distinct 
sets  of  motor  fibres  united  with  fibres  of  the  hypoglossal,  viz.,  fibres  convey- 
ing inspiratory  impulses,  fibres  conveying  expiratory  impulses,  and  fibres 
conveying  oesophageal  impulses,  the  first  two  sets  no  doubt  consisting  of 
fibres  of  the  vagus  going  through  the  recurrent  laryngeal  to  the  muscles 
of  the  larynx,  and  the  latter  set  forming  part  at  least  of  the  fibres  belong- 
ing to  the  same  branch. 

Another  interesting  fact  to  be  noted  is  that  the  sensory  fibres  in  the 
trunk  of  the  hypoglossal  at  the  point  of  union  with  the  vagus  in  these  ex- 
periments, are  recurrent  fibres  (sensory  fibres  coming  from  the  superior 
cervical  nerves  through  the  descending  branch  of  the  hypoglossal  and 
running  from  the  branch  towards  the  centre),  and  accordingly  conduct 
impressions  normally  not  directly  toward  the  centres,  as  is  commonly  the 
case  with  sensory  nerves,  but  first  peripherally  making  a  circuit,  as  it 
were,  before  reaching  the  centres ;  therefore,  since  the  sensory  fibres 
in  the  hypoglossal  which  united  with  the  sensory  fibres  in  the  vagus, 
conducted  impressions  to  the  vagus  fibres,  it  is  obvious  that  these  impres- 
sions were  conducted  in  a  direction  opposite  to  that  of  the  normal,  thus 
offering  corroborative  testimony  to  the  very  interesting  experiment  of 
Paul  Bert  in  showing  that  sensory  fibres  can  convey  impressions  in  both 
directions.  This  experiment  of  Prof.  Bert  is  one  of  such  interest  that  it 
may  be  quoted  with  profit.  He  laid  bare  a  portion  of  the  back  of  a  rat, 
and  also  a  part  of  the  end  of  the  tail,  and  caused  this  end  of  the  tail  to 
grow  to  the  back.  After  reunion  was  accomplished,  the  tail  was  cut  from 
the  body  at  the  root,  so  that  it  was  now  only  connected  to  the  body  by 
the  end  of  the  tail  grown  to  the  back.  He  now  found  that  when  he  irri- 
tated the  end  of  the  tail,  which  was  formerly  the  root,  the  animal  gave 


156  Reichert,  Regeneration  of  the  Vagus.  [Jan. 


signs  of  pain,  thus  showing  that  the  impressions  were  conveyed  in  a  direc- 
tion directly  opposite  to  that  normally,  or,  in  other  words,  that  the  nerve 
which  formerly  conveyed  impulses  from  the  end  of  the  tail  towards  the 
root,  now  conveys  impulses  in  an  opposite  direction. 

Explanation  of  Tracings  1  to  10  In  all  of  these  tracings  the  upper 

tracing  represents  the  movements  of  the  thorax,  the  rise  of  the  marker 
corresponding  to  inspiration  ;  the  lower  line  represents  the  time  of  the 
occurrence  of  the  contraction  in  an  observed  area  in  the  tongue,  the 
rise  of  the  marker  corresponding  to  contraction.  In  tracings  3  to  8  inclu- 
sive, the  first  method  of  recording  (p.  149)  was  adopted,  and  in  the  others 
the  second  method. 


Tracing  1. 


1885.] 


Reichert,  Regeneration  of  the  Vagus. 


Tracing  7. 


Reich ert,  Regeneration  of  the  Vagus. 


[Jan. 


Tracing  8. 


Tracing  10. 


1885.]  Reichert,  Regeneration  of  the  Vagus.  159 


Explanation  of  Tracings  H  and  12  The  X  indicates  the  time  of 

electrical  stimulation ;  the  I  indicates  the  cessation  of  stimulation  ;  V 
indicates  the  occurrence  of  vomiting. 


Schiff's  Laboratory,  Geneva, 
September,  1884. 


160  Balleeat,  Erysipelas  in  Pregnancy  and  Labor.  [Jan. 


Art.  XIII. 

Erysipelas  as  a  Complication  of  Pregnancy  and  Labor  ;  with  a 
Report  of  a  Case  of  Herniotomy,  performed  on  a  Patient  suffer- 
ing from  Erysipelas.  By  G.  H.  Balleray,  M.D.,  Surgeon  to  St.  Jo- 
seph's Hospital,  and  the  Ladies'  Hospital,  Paterson,  N.  J.,  and  to  the 
Woman's  Hospital,  Newark,  N.  J. 

The  interesting  paper  of  Dr.  Wra.  L.  Ward  well,  on  "  Erysipelas  com- 
plicating Pregnancy,"  which  appeared  in  the  number  of  the  American 
Journal  of  the  Medical  Sciences  for  April,  1884,  induced  me  to 
put  the  following  cases  on  record  : — 

Case  I  Was  called  in  July,  1876,  to  attend  Mrs.  R.,  aged  26,  who 

was  daily  expecting  her  confinement,  and  found  her  suffering  from  a  very 
severe  attack  of  facial  erysipelas.  I  had  attended  her  in  her  first  labor, 
three  years  previously,  and  had  not  forgotten  the  anxiety  which  she  caused 
me  on  that  occasion  in  consequence  of  a  severe  attack  of  scarlet  fever, 
which  developed  thirty-six  hours  after  delivery.  When  I  was  called  to 
see  her  this  second  time  and  found  her  suffering  from  erysipelas  in  a 
severe  form,  I  felt  that  should  delivery  occur  during  the  progress  of  the 
disease,  as  it  undoubtedly  would,  the  patient  would,  in  all  probability, 
die  of  blood-poisoning.  On  the  second  day  of  the  disease,  labor  came  on, 
and  the  patient  was  delivered  of  a  healthy,  living  male  child.  I  directed 
that  the  vagina  be  syringed  out  every  six  hours  with  hot  water,  followed 
by  a  weak  carbolic  solution  ;  and  that  the  treatment  to  which  the  patient 
had  been  subjected  previous  to  delivery  be  continued.  Stimulants  and 
concentrated  liquid  nourishment  were  given  freely.  The  disease  pursued 
its  usual  course,  and  the  puerperal  convalescence  seemed  to  be  in  no  wise 
affected  by  it.  On  the  fifth  day  of  the  disease  (third  day  after  delivery), 
the  temperature,  which  at  one  time  reached  104|°,  began  to  decline,  and 
the  pulse  became  less  frequent.  On  the  seventh  day,  the  temperature  was 
101 1°  ;  pulse  96.  On  the  ninth  day,  the  temperature  was  99°  ;  pulse  84: 
from  that  time  on,  convalescence  was  uninterrupted.  At  no  time,  during 
the  progress  of  the  disease,  was  there  pain  or  tenderness  over  the  uterus ; 
the  lochial  discharge  was  not  suppressed,  and  was  no  more  offensive  than 
it  frequently  is  after  an  uncomplicated  labor.  The  secretion  of  milk  was 
moderately  abundant,  and  the  patient  nursed  her  child. 

There  seems  to  be  a  difference  between  the  poisons  of  erysipelas  and 
scarlatina  as  regards  the  influence  which  they  exert  on  the  secretion  of 
milk  and  on  the  lochia.  In  the  case  of  this  patient,  who  had  a  severe 
attack  of  scarlatina  after  the  birth  of  her  first  child,  there  was  complete 
suppression  of  the  secretion  of  milk  and  of  the  lochial  discharge  ;  and  my 
experience  of  puerperal  scarlatina,  which  amounts  to  seven  cases,  leads 
me  to  believe  that  these  phenomena  are  constant  accompaniments  of  that 


1885.]       Balleray,  Erysipelas  in  Pregnancy  and  Labor.  161 


disease  when  it  occurs  shortly  after  delivery ;  whereas,  in  the  two  cases 
of  erysipelas  complicating  labor,  which  have  come  under  my  observation, 
the  lacteal  secretion  and  the  lochial  discharge  were,  apparently,  unaffected. 

Case  II — In  January,  1879,  after  an  absence  of  a  few  days,  I  met,  on 
my  return,  my  friend,  Dr.  Marsh,  who  seemed  to  be  particularly  glad  to 
see  me.  I  soon  learned  that  this  emotional  state  was  due  to  the  fact  that 
the  doctor  had  under  his  care  a  patient  of  mine,  who  was  hourly  expect- 
ing to  be  confined,  and  who  was  suffering  from  a  severe  attack  of  facial 
erysipelas.  The  doctor,  very  properly,  regarded  the  complication  with 
dread ;  and  I  inferred  from  what  he  said,  that  it  would  afford  him  much 
pleasure  to  turn  the  case  over  to  me,  and  that,  if  the  patient  must  die,  he 
would  somewhat  prefer  that  she  should  die  on  my  hands.  On  visiting 
the  patient,  I  found  her  with  a  pulse  of  118  ;  temperature  103|°.  I  in- 
formed the  husband  of  the  dangerous  nature  of  the  case,  and  directed  that 
the  treatment,  advised  by  Dr.  Marsh,  be  continued.  The  same  night  I 
was  sent  for,  and  found  that  the  patient  had  had  labor-pains  for  about 
three  hours.  I  found  the  os  dilated  to  tlie  size  of  a  dollar ;  head  present- 
ing, in  the  first  position.  My  experience  with  the  patient  in  her  three 
previous  labors  led  me  to  believe  that  she  would  soon  be  delivered.  In 
about  an  hour,  a  healthy  female  child  was  born.  The  placenta,  as  in  the 
previous  case,  was  delivered  by  Crede's  method ;  but,  in  both  cases,  I  ab- 
stained from  my  usual  custom  of  introducing  a  finger  up  to  the  os  uteri 
(after  the  delivery  of  the  after-birth),  to  ascertain  if  any  shreds  of  mem- 
branes can  be  felt.  A  dose  of  ergot  was  given  after  the  delivery  of  the 
placenta,  and  gentle  manipulation  of  the  uterus  was  continued  until  the 
organ  was  firmly  contracted.  In  the  after-treatment  of  the  case,  thorough 
ventilation  of  the  room,  perfect  cleanliness,  and  the  use  of  hot  carbolized 
vaginal  injections  were  the  only  measures  insisted  upon.  On  the  tenth 
day  after  delivery  I  ceased  my  attendance ;  the  patient  being  convalescent* 

The  management  of  labor  in  the  case  of  a  woman  suffering  from  ery- 
sipelas does  not  materially  differ,  other  things  being  equal,  from  the 
management  of  a  case  of  normal  labor.  The  accoucheur  should  abstain 
from  frequent  vaginal  examinations  during  labor ;  and  such  examinations 
as  are  necessary  should  be  made  with  clean  hands.  The  placenta  should, 
if  possible,  be  delivered  by  Crede's  method ;  thus  avoiding  the  introduc- 
tion of  the  finger  or  hand  within  the  genital  canal.  A  full  dose  of  ergot 
should  be  given  after  the  delivery  of  the  placenta ;  and  the  uterus  should 
be  gently  manipulated  until  it  is  jirmly  contracted.  In  the  after-treat- 
ment, the  nurse  should  be  forbidden  to  touch  the  genitals  of  the  patient, 
without  having  previously  washed  her  hands  thoroughly  with  hot  water 
and  soap.  The  use  of  antiseptic  vaginal  injections  should  be  commenced 
within  twelve  hours  after  delivery,  and  continued  so  long  as  there  is  any 
indication  for  their  employment.  Some  of  our  rigid  antisepticists  would 
probably  recommend  that  the  patient  be  delivered  under  a  cloud  of  car- 
No.  CLXXVII— Jan.  1885.  11 


162 


Ballekay,  Erysipelas  in  Pregnancy  and  Labor.  [Jan. 


bolic  acid  spray,  and  that  immediately  after  delivery,  Garrigues's  anti- 
septic pin-cushion  be  tacked  over  the  vulva.  These  extraordinary 
precautions  were  not  adopted  in  the  two  cases  above  narrated,  and  their 
omission  does  not  seem  to  have  been  productive  of  harm. 

As  regards  erysipelas  occurring  during  the  early  months  of  pregnancy, 
my  experience  is  limited  to  two  cases.  One  was  a  patient  who  was  ad- 
mitted into  St.  Joseph's  Hospital,  between  the  third  and  fourth  months 
of  pregnancy.  She  recovered  from  the  attack  of  erysipelas,  and  was,  I 
understand,  safely  delivered  at  full  term.  The  other  was  a  private  patient, 
who  was  attacked  with  erysipelas  when  in  the  third  month  of  pregnancy. 
She  also  went  safely  through  ihejiery  ordeal,  and  was  delivered  of  a  healthy 
living  child  six  months  later.  Erysipelas  occurring  in  a  pregnant  or 
puerperal  woman  calls  for  no  special  medication  ;  the  treatment  of  the 
disease  under  these  circumstances  being  the  same  as  when  it  occurs  inde- 
pendently of  these  conditions.  There  is  one  remedy,  however,  which  is 
particularly  serviceable  in  the  class  of  cases  under  consideration  :  viz., 
opium.  It  should  be  given  in  doses  sufficient  to  tranquillize  and  soothe  the 
nervous  system,  and  procure  sleep  at  night. 

Although  foreign  to  the  subject  of  puerperal  erysipelas,  the  following 
case  may  not  be  devoid  of  interest  in  this  connection  : — 

Case  III  In  May,  1880,  I  was  asked  by  Dr.  E.  J.  Marsh  to  see,  in 

consultation  with  him,  a  Mr.  M.,  80  years  of  age,  who  was  suffering  from 
an  attack  of  facial  erysipelas,  which  had  commenced  the  day  before,  and 
who  was  also  the  subject  of  a  strangulated  inguinal  hernia.  I  saw  the 
patient  at  11  P.  M.  The  hernia  was  tense,  and  painful  to  the  touch,  and 
the  patient  had  vomited  several  times.  I  learned  that  the  patient  got  out 
of  bed  without  his  truss  in  the  early  part  of  the  day,  and  that  the  hernia 
at  once  came  down,  and  shortly  afterwards  became  troublesome.  The  old 
gentleman  then  attempted  to  reduce  it  himself,  but  without  success.  He 
then  sent  for  Dr.  Marsh,  who  tried  to  reduce  it,  but  failed.  In  view  of 
the  lateness  of  the  hour,  I  suggested  to  Dr.  Marsh  to  give  the  patient  a 
dose  of  morphia,  and  wait  until  early  the  following  morning,  then  admin- 
ister ether,  and  attempt  the  reduction  of  the  hernia;  and  failing  in  this, 
to  proceed  to  perform  herniotomy. 

Dr.  Marsh  did  not  receive  my  suggestion  in  reference  to  herniotomy 
with  much  enthusiasm.  He  evidently  took  a  most  melancholy  view  of 
the  case.  In  fact  he  stated,  as  his  opinion,' that  should  it  be  necessary  to 
resort  to  a  cutting  operation  to  effect  the  reduction  of  the  hernia,  the 
operation  wound  would  almost  certainly  be  attacked  by  erysipelas,  and 
that  death  would  be  the  result.  Courtesy,  however,  if  not  conviction, 
caused  him  to  yield  assent  to  my  proposition. 

My  experience  with  the  puerperal  cases  above  referred  to  made  me 
more  hopeful  than  Dr.  Marsh,  and  besides  there  was  another  circumstance 
which  to  my  mind  argued  in  favor  of  the  course  which  I  advised,  viz.,  it 


1885.] 


White,  Psoriasis — Verucca — Epithelioma. 


1G3 


was  the  only  thing  that  could  be  done,  except  to  let  the  patient  die  with- 
out making  an  attempt  to  save  his  life.  On  the  following  morning  ether 
was  administered,  and  Dr.  Marsh  made  a  faithful  attempt  to  effect  the 
reduction  of  the  hernia,  but  did  not  succeed.  He  then  requested  Dr. 
Calvin  Terri berry  and  myself  to  try,  but  we  both  declined,  as  we  felt  that 
any  further  manipulation  would  be  detrimental ;  and,  moreover,  we  both 
had  perfect  confidence  in  Dr.  Marsh's  skill,  and  believed  that,  if  it  were 
possible  to  reduce  the  hernia  by  taxis,  he  would  have  succeeded  in 
doing  so.  Herniotomy  being  the  only  alternative,  Dr.  Marsh  proceeded 
to  operate.  The  doctor  is  a  faithful  disciple  of  Mr.  Lister,  and  the  de- 
tails of  the  antiseptic  system,  including  the  use  of  the  spray,  were  carried 
out  to  the  letter.  In  order  to  divide  the  stricture  it  became  necessary  to 
open  the  sac.  The  intestine  was  deeply  congested,  but  the  color  im- 
proved after  division  of  the  constriction  ;  it  was,  therefore,  returned  to 
the  abdominal  cavity.  Considering  the  age  of  the  patient,  convalescence 
from  the  operation  was  rapid.  The  wound  healed  kindly,  the  reparative 
process  being  apparently  unaffected  by  the  existence  of  the  facial  ery- 
sipelas. 

I  now  frequently  meet  the  patient  on  the  street,  and  he  looks  as  if  he 
might  live  ten  years  longer. 

This  case  is  interesting,  as  demonstrating  the  fact  that  a  patient  suffer- 
ing from  severe  erysipelas  of  the  face  may  undergo  a  serious  surgical  ope- 
ration without  developing  erysipelas  in  the  operation  wound.  Not  having 
had  the  leisure  to  look  up  the  literature  of  the  subject,  I  am  unable  to 
state  whether  or  not  any  similar  case  has  ever  been  reported.  To  what 
extent  the  employment  of  rigid  antiseptic  measures  contributed  to  the 
good  result,  it  is  of  course  impossible  to  say  ;  but,  in  view  of  the  risks  of 
such  an  operation  under  such  unfavorable  circumstances,  the  surgeon  who 
would  fail  to  protect  his  patient  by  all  the  safeguards  known  to  science 
would  be  lacking  in  a  proper  sense  of  his  own  responsibility. 


Article  XIV. 
Psoriasis — Verruca — Epithelioma  ;  a  Sequence.1 
By  James  C.  White,  M.D.,  Professor  of  Dermatology  in  Harvard  University. 

It  is  my  purpose  in  this  paper  to  present  brief  notes  of  two  remarkable 
cases  of  disease — cases  extraordinary,  not  for  the  rarity  of  the  patho- 
logical processes  they  represent,  but  for  the  very  unusual  sequence  of  tis- 
sue-change exhibited  in  their  course. 


1  Read  before  the  Boston  Society  for  Medical  Improvement,  November  24,  1884. 


164 


White,  Psoriasis — Verucca — Epithelioma. 


[Jan. 


Case  I  In  1866,  a  gentleman,  set.  27,  consulted  me  on  account  of 

psoriasis.  It  had  first  manifested  itself  six  years  previously,  and  had  re- 
mained constantly  present  in  some  degree  up  to  this  date,  nearly  disap- 
pearing each  summer,  but  increasing  again  in  intensity  in  the  winter,  in 
spite  of  considerable  doses  of  Fowler's  and  Donovan's  solutions,  which 
had  been  taken  from  time  to  time.  The  disease  had  not  been  known  in 
the  family  in  other  generations,  and  the  patient's  health  had  otherwise 
been  uniformly  excellent.  At  this  time  the  only  portions  of  the  integu- 
ment affected  were  the  forehead,  chest,  and  arms.  The  type  of  the  dis- 
ease was  guttata  and  nummularis,  and  the  patches  presented  a  marked 
degree  of  hyperremic  activity,  to  such  a  degree  in  fact  that  they  were 
greatly  excited  by  such  stimulating  applications  as  Vleminckx's  solution, 
and  tincture  of  German  soap  and  oil  of  cade,  which  were  at  that  time 
employed  ;  and  in  fact  the  skin  then  and  subsequently  showed  itself  un- 
usually intolerant  of  active  external  remedies,  to  such  a  degree  that  Fow- 
ler's solution  was  again  advised  as  the  only  hopeful  or  possible  means  of 
relief.  The  case  remained  under  my  occasional  observation  for  ten  or 
twelve  years  without  marked  features  of  interest,  but  during  all  this  time 
it  retained  an  extraordinary  obstinacy  to  all  methods  of  treatment,  exter- 
nal or  internal,  which  were  employed,  many  of  them  the  new  remedies 
introduced  into  the  materia  medica  of  the  disease  in  that  period.  The 
disease  in  the  mean  time  manifested  its  own  independent  vagaries  of  ad- 
vance and  retrogression,  now  and  then  covering  large  areas  of  the  gene- 
ral surface  of  the  body,  but  never  wholly  disappearing  from  certain  local- 
ities, as  the  scalp  and  backs  of  the  hands. 

Ten  years  ago  several  of  the  patches  upon  the  latter  parts  and  the  lower 
forearms  especially,  began  to  undergo  a  change.  Their  bases  became  less 
hyperaemic,  and  they  themselves  more  elevated  and  less  scaly,  until  they 
were  gradually  converted  into  sharply-defined,  prominent,  firm,  and  horny 
outgrowths,  some  of  them  resembling  the  unpigmented  formations  of 
keratosis  senilis  in  the  same  localities,  while  others  were  more  like  callo- 
sities or  some  form  of  warts. 

Three  years  ago  one  of  these  outgrowths,  situated  upon  the  right  palm 
near  the  wrist  in  one  of  the  great  longitudinal  dividing  furrows  of  the 
skin,  became  excoriated  either  by  abrasion  or  Assuring,  which  refused  to 
heal  by  the  simple  measures  employed,  and  terminated  in  a  small  ulcer. 
It  remained  in  this  condition  many  months,  sometimes  nearly  filling  up 
and  protecting  itself  with  a  thin  epithelial  cover,  sometimes  breaking 
down  again  and  remaining  in  an  open,  indolent  condition,  but  the  de- 
structive process  gradually  extended  more  deeply  into  the  cutaneous  tis- 
sues and  widened  its  borders.  After  a  time  the  peripheral  portions  of  the 
integument  became  indurated  and  thickened,  forming  a  dense  and  elevated 
circumvallation  about  the  central  ulceration.  During  this  long  period  the 
efforts  to  restore  the  part  to  a  healthy  condition  were  persistent  and  vari- 
ous ;  at  first  simply  soothing  applications  combined  with  restraint  to  the 
movements  of  the  part,  afterwards  more  stimulating  applications,  then 
cauterizing  agents,  as  chromic  and  concentrated  nitric  acids,  and  later  the 
curette.  Finally,  as  the  ulcer  enlarged  and  deepened,  so  that  the  integu- 
ment involved  in  the  destructive  process  and  surrounding  induration  was 
one-half  inch  in  area,  the  whole  growth  in  August,  1883,  was  deeply 
scraped.  At  the  same  time  another  lesion  identical  in  history  and  charac- 
ter, but  of  much  smaller  size,  which  had  more  recently  and  gradually 
established  itself  upon  one  of  the  warty  hypertrophies  situated  upon  the 


1885.] 


White,  Psoriasis — Verucca — Epithelioma. 


165 


palmar  fold  of  skin  between  the  fore  and  middle  fingers  of  the  left  hand, 
was  also  thoroughly  curetted. 

These  more  radical  operations  were,  however,  as  unsuccessful  as  the 
measures  previously  employed.  The  wound  closed  up,  and  some  sort  of 
epidermal  covering  was  established,  but  the  areas  primarily  affected  be- 
came the  seat  of  a  much  more  rapidly  progressive  induration  and  thicken- 
ing, so  that  the  integument  of  the  right  palm  became  involved  in  the 
process  to  the  extent  of  more  than  an  inch  in  circumference,  and  pre- 
sented subsequently,  at  the  beginning  of  this  year,  at  a  consultation  held  by 
Prof.  Henry  J.  Bigelow,  and  Dr.  R.  M.  Hodges,  under  whose  skilful  and 
constant  surgical  care  the  case  had  been  for  a  long  time,  with  the  writer, 
a  reddened  prominence,  largely  occupying  the  lower  third  of  the  palm,  of 
somewhat  uneven  surface,  in  the  centre  of  which  a  new  ulcer  had  estab- 
lished itself  with  an  everted  edge  of  exuberant  fungoid  granulations.  To 
the  touch  the  rest  of  the  mass  was  deeply  resisting,  except  in  one  or  two 
parts,  where  boggy-feeling  globular  elevations  the  size  of  a  large  pea,  and 
somewhat  translucent,  existed.  These  had  also  formed  in  the  neighbor- 
hood of  the  ulcer  before  the  last  operation.  Upon  the  other  hand,  too, 
the  tissues  surrounding  the  seat  of  the  curetted  ulcer  were  becoming 
rapidly  indurated  to  a  much  greater  extent  than  previously.  The  bra- 
chial and  axillary  glands  remained  unaffected.  The  parts  had  been  ex- 
cessively painful  for  a  long  time,  and  the  patient's  strength  was  giving  way 
under  his  suffering  and  anxiety.  His  medical  attendants  had  long  pre- 
viously formed  an  opinion  that  the  disease  had  become  epitheliomatous  in 
character,  and  were  then  of  the  unanimous  conclusion  that  it  could  be 
overcome  only  by  thorough  removal  of  the  affected  tissues.  The  growth 
had  penetrated  so  deeply  that  a  radical  local  excision  of  the  diseased  parts 
alone  was  no  longer  possible,  so  that  amputation  of  the  right  hand  and  of 
as  much  of  the  left  as  was  involved  in  the  diseased  process  was  advised. 
Before  resorting  to  such  extreme  measures,  however,  it  was  thought  ad- 
visable by  them,  considering  the  rare,  or  even  unparalleled,  history  of  the 
case,  that  the  patient  should  have  the  benefit  of  the  opinion  also  of  cer- 
tain distinguished  dermatologists  and  surgeons  in  Europe,  and  accordingly 
he  proceeded  thither  in  January  of  this  year  and  consulted  Mr.  Hutchin- 
son and  Sir  James  Paget,  of  London,  and  Professors  Kaposi  and  Billroth, 
in  Vienna. 

On  his  return,  after  an  absence  of  six  or  seven  weeks,  during  which  he 
had  the  personal  attention  of  Dr.  G.  W.  West,  the  disease  was  found  to 
have  made  great  advance.  The  skin  of  the  whole  palm  of  the  right  hand 
had  apparently  become  implicated  in  the  process,  and  the  lower  half  was 
fully  occupied  by  a  deep  ulcer  with  dense,  enormously  everted  edges  in  a 
state  of  flamboyant  granulation,  encroaching  at  its  inferior  part  upon  the 
wrist.  The  ulcer  upon  the  left  hand  had  also  extended  rapidly,  and  was 
assuming  the  same  fungous,  exuberant  appearance  as  the  other.  The 
patient's  general  condition  had  naturally  become  decidedly  worse,  for  the 
prognosis  had  not  been  lightened  by  the  opinions  he  had  obtained  from 
the  eminent  professional  gentlemen  above  named,  and  the  affected  parts 
were  excessively  painful,  so  that  sleep  was  obtained  only  by  the  aid  of 
narcotics.  As  it  was  decided  by  his  medical  attendants  after  repeated 
consultations  that  nothing  was  to  be  gained  by  further  delay  he  consented 
to  submit  to  the  measures  previously  advised,  and  in  April  last  the  right 
hand  was  amputated  above  the  wrist,  and  the  fore  and  middle  fingers  of 
the  left  hand  were  excised  through  the  middle  of  the  metacarpal  bones  by 


166 


White,  Psoriasis — Verucca — Epithelioma. 


[Jan 


Dr.  Hodges.  The  wounds  healed  quickly  and  properly,  and  the  long- 
continued  sources  of  mental  and  physical  irritation  having  been  thus 
wholly  removed,  the  patient  regained  his  old  condition  of  good  health,  and 
the  tissues  bordering  upon  the  former  seats  of  disease  have  remained  in 
their  normal  state. 

The  parts  removed  were  given  to  Prof.  Fitz  for  examination,  who 
makes  the  following  report :  "  The  palm  of  the  right  hand  presented  an 
elevated,  rounded,  ulcerating  mass  with  dense  everted  edges  and  irregu- 
larly scalloped  outline.  The  surface  for  the  most  part  was  smooth,  red- 
dish-gray, and  translucent,  but  showed  an  irregular  deep,  sinuous  depres- 
sion at  the  upper  and  outer  fourth.  It  measures  two  and  a  quarter  by 
three  and  a  third  inches,  and  the  mass  projected  two-thirds  of  an  inch 
above  the  cutaneous  surface. 

"  On  section  the  superficial  ulcer  corresponded  with  a  circumscribed  new 
formation,  one  and  a  quarter  inches  in  thickness,  extending  through  the 
skin  and  subcutaneous  fat  tissues  to  the  deep  fascia,  being  intimately 
united  to  the  tendinous  sheaths,  which  were  not  perforated.  The  growth 
was  continued  into  the  substance  of  the  unciform  bone  and  into  the  ab- 
ductor minimis  digiti.  The  cut  section  was  in  general  relatively  homo- 
geneous, gray,  and  translucent.  Minute  ecchymoses  were  present  near  its 
tree  edge,  and  occasional  opaque  lines  extended  upwards  and  outwards 
from  the  base.  Pressure  caused  the  escape  of  small,  soft,  opaque,  white 
plugs. 

"The  microscopic  examination  showed  that  the  structure  was  composed 
of  variously  shaped,  anastomosing  bands  of  cells,  resembling  the  deeper 
layers  of  the  epidermis,  and  separated  by  a  framework  of  fibrous  tissue. 
The  bands  contained  numerous  onion-shaped  bodies  of  laminated  epider- 
moid cells,  and  extended  irregularly  in  all  directions. 

"At  the  palmar  base  of  the  fore  and  middle  finger  of  the  left  hand  wras  a 
small,  superficial  ulcer  upon  the  surface  of  a  dense  rounded  and  flattened 
nodule,  one  by  one  and  a  half  inches  in  length  and  breadth,  and  three- 
fourths  of  an  inch  in  depth.  The  cut  section  of  the  nodule  showed  a  gray, 
slightly  translucent  new  formation  traversed  by  occasional  fibres.  The 
growth  extended  into  the  subcutaneous  fat  tissue,  and  the  tendons  beneath 
were  freely  movable.  The  structure  was  like  that  of  the  growth  on  the 
right  hand,  though  the  fibrous  portion  was  relatively  more  abundant,  and 
in  both  the  characteristic  appearances  of  flat  cell,  epidermoid  cancer  wrere 
presented." 

This  case  presents,  therefore,  three  distinct  pathological  affections  of 
the  cutaneous  tissues  ;  psoriasis,  verrucous  hypertrophy,  and  epithelioma- 
tous  new  growth  ;  not  occurring  independently  of  each  other,  but  as  suc- 
cessive, mutual  transformations  in  the  above  order.  It  is  this  sequence 
which  constitutes  its  peculiar  features.  I  cannot  find  its  like  recorded  in 
dermatological  literature.  Psoriasis  has  in  very  rare  instances  developed 
into  warty  growths  in  certain  localities  ;  verrucae,  as  is  well  known,  not 
unfrequently  degenerate  into  epithelioma ;  but  no  case  is  on  record,  so  far 
as  my  knowledge  extends,  of  psoriasis  terminating  in  cutaneous  carcinoma 
through  this  or  other  intermediate  transformation.  Psoriasis  is  among 
the  more  common  affections  of  the  skin,  1924  cases  having  been  recorded 
in  the  58,617  cases  of  cutaneous  disease  reported  by  members  of  the 


1885.] 


White ,  Psoriasis — Verucca — Epithelioma. 


167 


American  Dermatological  Association  in  its  combined  returns  of  five 
years,  a  ratio  equal  to  3.28  per  cent.  It  is,  therefore,  a  matter  of  fre- 
quent observation,  and  no  disease  of  the  integument  presents  a  more 
regular  course,  a  greater  uniformity  and  simplicity  of  lesions,  and  a  more 
indifferent  relation  to  the  economy  as  a  whole  than  it.  It  might  have 
been  predicted  in  every  individual  case  before  this,  as  far  as  the  recorded 
experience  of  dermatologists  reaches,  that  the  disease  could  lead  to  no 
serious  results  directly  or  indirectly. 

Let  us  consider  what  is  the  nature  of  this  affection,  and  what  connection 
there  may  be  between  it  and  the  other  two  processes  with  which  it  is  so 
intimately  associated  in  this  case.  Psoriasis  has  been  generally  regarded  as 
an  inflammatory  process  of  the  skin,  and  in  most  works  on  dermatology  it 
is  placed  among  the  inflammatory  or  exudative  affections.  Hebra,  how- 
ever, in  his  latest  edition,  laid  greater  stress  upon  its  relation  to  simple 
epidermal  hyperplasy,  and  his  son,  in  his  recent  work — Die  krankhaften 
Ver'dnderungen  der  Haut — describes  it  as  a  local  epithelial  hyperplasy 
produced  by  the  quantitative  increase  and  qualitative  (alienation)  change 
in  all  the  epidermal  strata.  Dr.  A.  R.  Robinson,  of  New  York,  was 
among  the  first  to  recognize  the  essential  anatomical  nature  of  the  disease, 
and  to  show  by  thorough  microscopical  study  that  it  is  not  primarily  an 
inflammatory  affection  of  the  papillary  layer  of  the  corium.  In  the  begin- 
ning the  process  is  simply  one  of  hyperplasy  of  the  Malpighian  layer,  and 
the  apparent  hypertrophy  of  the  papillae  is  the  result  of  the  extension 
downwards  of  the  newly-formed  rete  cells,  the  intermediate  papilla?  not 
being  elevated  above  the  general  level  of  their  tips  in  the  surrounding 
healthy  skin.  Later  the  bloodvessels  of  the  papillae  become  dilated,  serum 
and  white  corpuscles  exude,  and  these  conditions  with  the  great  increase 
of  epidermal  development  give  rise  to  the  redness  and  thickening  of  the 
skin.  The  important  points  established  by  Dr.  Robinson's  investigations 
are  that  the  hyperplasy  precedes  the  hyperemia,  so  that  any  inflammatory 
phenomena  in  the  tissues  of  the  cutis  are  to  be  regarded  as  secondary  and 
not  essential  features  of  the  disease.1  Of  the  reality  and  intensity  of  the 
inflammation  of  the  cutaneous  tissues  which  not  unfrequently  accompanies 
the  disease  there  can  be  no  question.  This  is  of  most  common  occurrence 
in  the  early  stages  of  universal  psoriasis  of  rapid  evolution,  but  occasion- 
ally accompanies  individual  cases  throughout  their  course.  The  dermatitis 
at  times  amounts  to  a  true  eczema,  and  often  demands  special  treatment 
for  its  relief  before  the  proper  and  more  stimulating  applications  for  the 
psoriasis  can  be  employed. 

Auspitz,  in  his  System  der  Hautkrankheiten  (Wien,  1881),  has  con- 
tributed a  valuable  chapter  to  our  knowledge  on  the  classification  of  affec- 
tions of  the  epidermis,  among  which  he  places  psoriasis.    This  seventh 


1  New  York  Medical  Journal,  July,  1878. 


168 


White,  Psoriasis — Verucca — Epithelioma. 


[Jan. 


class  of  his  system  contains  the  following  subdivisions,  which  in  their 
mutual  relations  are  of  especial  interest  in  connection  with  the  cases  under 
our  consideration,  as  shown  in  the  accompanying  table : — 

7th  Class. — Epidermidoses  =  Anomalies  in  the  growth  of  the  cuticle. 
A.  Keratonoses  =  Anomalies  of  formation  of  the  horny  layer. 

Family  II.  Parakeratoses  =  Quantitative  anomalies  in  the  pro- 
cess of  eornification. 
Psoriasis. 

C.  Akanthoses  =  Anomalies  of  the  prickle  layer  of  the  epidermis. 
Family  I.  Hyperkanthoses  =  Simple  akanthoma. 

Verruca  =  Warty  akanthoma. 
Family  II.  Parakanthoses  =  Alveolar  akanthoma. 

Epithelioma.    (With  eornification  of  the  cells  of  the  new 
growth.) 

He  recognizes  the  following  anatomical  changes  as  of  constant  occur- 
rence in  psoriasis  ;  an  increased  thickness  of  the  horny  layer  ;  certain 
changes  in  the  stratum  granulosum  and  stratum  spinosum  indicating  more 
rapid  transformation  in  their  development  than  is  natural,  as  shown  by 
an  increase  of  the  nuclei  in  the  deeper  layers  of  the  prickle  cells  and  a 
more  abundant  granulation  in  the  uppermost,  in  those  undergoing  trans- 
formation into  the  true  granular  cells,  together  with  a  more  rapid  loss  of 
their  spines,  and  a  thicker  superposition  and  change  in  form  of  the  cells 
of  the  cylindrical  layer ;  and,  finally,  an  overfilling  of  the  papillary  capil- 
laries. He  regards  the  disease,  therefore,  not  as  an  inflammatory  affection, 
but  as  an  anomaly  of  the  process  of  eornification  of  the  epidermis,  and  im- 
perfect transformation,  that  is,  of  its  cells,  so  that  those  of  the  horny  layer 
do  not  adhere  closely,  and  form  dry  and  scaly  elevations,  while  the  younger, 
deeper  layers  are  also  less  adherent,  so  that  the  cylindrical  layer  is  easily 
laid  bare  above  the  hypenemic  tips  of  the  papilla?,  which  bleed  readily  on 
such  denudation. 

In  verrucce  we  have  a  quantitative  change  in  the  formation  of  the 
stratum  spinosum,  an  excessive  formation  of  the  prickle  cells,  extending 
in  some  forms  far  downwards  into  the  corium  between  the  papillae,  thus 
simulating  a  marked  prolongation  or  hypertrophy  of  these  bodies.  The 
down-growth  of  the  epidermal  cells  is  always  continuous,  however,  and 
nipple-shaped  in  its  encroachments  upon  the  cutis.  The  cornified  cells  of 
the  upper  layers  are  magnified  in  quantity  in  the  same  proportion. 

Whenever  this  uniformity  or  continuity  of  epithelial  hypertrophy  or 
new  growth  is  interrupted  in  its  invasion  of  the  tissues  of  the  corium,  and 
the  epidermal  cells  are  found  seemingly  developed  in  separate  foci  below 
the  general  line  of  the  rete,  we  have  another  condition  to  which  we  apply 
the  title  epithelioma  or  carcinoma.  In  it  the  prickle  cells  are  arranged 
in  no  orderly  manner,  but  permeate  the  tissues  of  the  corium  in  all  direc- 
tions it  may  be,  or  congregate  in  nests  or  alveoli,  taking  their  origin  either 
from  the  cells  of  the  epidermis  or  from  their  continuations  along  the 
glandular  structures  of  the  cutis. 


1885.] 


White,  Psoriasis — Verucca — Epithelioma. 


169 


We  see,  therefore,  that  these  three  dermatoses  which  enter  into  the  clini- 
cal history  of  our  case,  and  which  are  in  their  nature  apparently  as  unlike 
as  their  companionship  is  rare,  have  a  close  affiliation  in  their  anatomical 
relations.  The  transformation  of  patches  of  psoriasis  into  horny  or  warty 
permanent  growths  is  not  referred  to  in  most  works  on  dermatology  as  of 
possible  occurrence  even  ;  the  transformation  of  verrucous  growths  into 
epithelioma  is  of  not  very  infrequent  occurrence ;  but  the  sequence  fol- 
lowed in  our  case,  psoriasis — verruca — epithelioma,  is  extremely  rare  or 
unparalleled  in  dermatological  history.  Milton  says1  "  there  is  a  form  of 
wart  so  like  lepra,2  or  of  lepra  so  like  wart,  that  I  am  at  a  loss  to  know 
which  it  is,"  and  in  one  of  the  three  cases  observed  by  him  the  growth 
"  began  as  lepra-spots  ;"  and  Gaskoin3  states  that  "  psoriasis  often  displays 
a  condition  which  shows  a  near  approach  to  warts." 

With  the  difficulty  of  distinguishing  palmar  psoriasis  at  times  from 
syphiloderma  of  this  part,  the  resemblance  of  these  secondary  callosities 
to  the  latter,  or  the  syphilide  cornee  of  French  writers,  is  worthy  of 
special  mention  in  connection  with  our  case.  To  one  who  had  not  ob- 
served the  disease  from  its  early  manifestations  and  watched  the  local 
changes  above  referred  to  step  by  step,  the  appearances  of  the  hands  alone, 
while  the  disease  was  in  a  quiescent  state  as  far  as  the  general  surface  was 
concerned,  might  have  suggested  the  question  of  their  syphilitic  character. 
They  were,  however,  well  marked  horny  concretions,  rising  above  the 
general  surface  in  the  form  of  prominent,  more  or  less  conical  elevations. 
They  had  not  that  appearance  of  being  embedded  or  encapsuled  in  the 
skin,  as  if  they  could  be  easily  enucleated,  nor  were  they  seated  upon  a 
hypersemic  base  or  surrounded  by  a  scaling  ring  or  wall-like  edge.  They 
were  in  reality,  what  close  observation  and  their  history  demonstrated, 
horny  concretions,  true  warty  growths  springing  up  from  the  seats  of  old 
patches  of  psoriasis.  In  other  words,  a  long-continued  process  of  modi- 
fied epidermal  formation  had  upon  parts  spontaneously  prone  to  such 
development  transformed  itself  into  a  permanent  hypertrophy  of  the  same 
cell  tissue. 

The  subsequent  change  is  of  far  less  uncommon  occurrence,  that  namely 
of  so-called  benignant  epidermal  growths  into  those  entitled  malignant. 
Epithelioma  may  follow  simple  prolonged  inflammation  of  the  cutaneous 
tissues,  as  in  the  so-called  Paget's  disease  of  the  nipple,  or  protracted 
granulation  formation,  as  in  the  exuberant  outgrowths  of  elephantiasis, 
chronic  ulcers  of  various  origin,  in  lupus,  old  fissures  of  the  lip  and 
elsewhere,  etc. ;  but  even  in  these  cases,  where  the  primary  disease  is 
seated  in  the  deeper  layers  of  the  skin,  the  epidermal  tissues  become 


1  Pathology  and  Treatment  of  Diseases  of  the  Skin,  London,  1872,  p.  329. 

2  The  word  lepra  is  here  used  in  the  British  sense,  synonymous  with  psoriasis. 

3  On  the  Psoriasis  or  Lepra,  London,  1875,  p.  87. 


170  "White,  Psoriasis — Yerucca — Epithelioma.  [Jan. 

involved  in  the  perverted  development  only  after  prolonged  efforts  to 
reproduce  themselves  in  proper  place  and  form.  It  is,  however,  in  the 
course  of  affections  of  the  epithelial  structures  of  the  skin  that  this  malig- 
nant transformation  is  most  frequently  observed.  The  most  common 
starting  point  of  epithelioma  of  the  face  in  all  its  clinical  varieties  from 
the  flat,  superficial  forms  to  the  "  rodent  ulcer,"  or  stages  of  deep  pene- 
tration, is  that  very  frequent  condition  of  imperfect  epidermal  formation 
after  middle  life  called  keratosis  senilis.  The  cutaneous  horn,  the  seba- 
ceous cyst,  both  modifications  of  the  epithelial  structures,  may  eventually, 
as  is  well  known,  undergo  transformation  into  this  disease,  and,  to  approach 
more  closely  to  the  anatomical  conditions  in  this  case,  the  pointed  condy- 
loma and  the  ordinary  verruca,  essentially  identical  in  structure  and 
primarily  an  epidermidosis  rather  than  a  papilloma,  may  also  terminate 
in  it.  Epithelioma  of  the  skin  may  be  said  not  only  to  follow  all  these 
affections  above  described,  but  to  rarely  occur  without  some  similar 
precedent  process. 

In  this  instance  two  factors  may  have  been  operative  in  the  develop- 
ment of  the  final  condition,  not  only  the  verrucous  hypertrophy  with  the 
possibilities  of  epitheliomatous  transformation  essentially  incident  to  it, 
but  the  prolonged  ulceration  and  granulation  of  the  cutaneous  tissues, 
which  may  at  first  have  been  simply  the  expression  of  futile  reparative 
efforts  in  a  part  of  less  vitality  than  the  surrounding  structures  and  ter- 
minating in  a  perversion  of  cell  development.  Whether  one  or  both  of 
these  agencies  were  active  and  just  when  the  epitheliomatous  transforma- 
tion was  established  in  this  case,  cannot  be  definitely  determined. 
Eventually  there  were  observed,  in  addition  to  the  slowly  progressive 
infiltration  and  destruction  of  the  surrounding  tissues,  the  development  of 
encysted  centres  of  secondary  metamorphosis  (colloid)  beyond  the  visible 
bounds  of  the  disease,  and  finally  a  most  rapid  outburst  of  exuberant 
fungoid  outgrowth. 

Thus  we  have  established  an  uninterrupted  sequence  of  psoriasis  through 
verruca  into  epithelioma,  or,  in  other  words,  psoriasis  as  a  cause  of  carci- 
noma. Of  so  serious  a  termination  of  so  common  an  affection  I  could 
find  no  record,  and  believed  that  the  case  would  remain  in  my  experience, 
as  long  in  the  future  as  in  the  past,  unique. 

Case  II  On  the  first  of  August  of  this  year  a  gentleman,  fifty-two 

years  old,  consulted  me  on  account  of  a.  sore  upon  his  hand  of  several 
years'  duration.  He  showed  me  an  ulcer  occupying  the  anterior  surface 
of  the  right  wrist,  extending  slightly  into  the  palm  of  the  hand,  about 
two  inches  in  length  and  one  and  a  half  inches  in  transverse  diameter. 
It  was  surrounded  by  a  very  prominent  and  indurated  border,  extending 
deeply  beneath  the  skin,  and  was  very  painful.  I  noticed  at  the  same 
time  upon  his  forehead  several  small,  slightly  elevated  patches,  red  and 
covered  with  thin  scales,  and  upon  the  hands  and  fingers  a  considerable 
number  of  horny,  wart-like  growths.    I  immediately  recognized  that  I 


1885.] 


White,  Psoriasis — Verucca — Epithelioma. 


171 


had  before  me  one  of  those  extraordinary  coincidences  of  the  simultaneous 
occurrence  of  disease  of  extreme  rarity.  Here  was  again  a  patient  who 
presented  general  psoriasis,  warty  growths  upon  the  hands,  and  unmistak- 
able epitheliomatous  disease.  What  was  their  connection  in  this  case  ?  I 
found  that  he  had  had  psoriasis  nearly  constantly  since  early  manhood,  and 
had  tried  various  methods  of  cure,  including  arsenic,  mostly  in  vain  as 
far  even  as  temporary  results.  Some  ten  years  ago  several  of  the  chronic 
patches  of  psoriasis  upon  his  hands  began  to  assume  a  thickened,  horny 
appearance,  and  transformed  themselves  into  true  warty  outgrowths. 
Some  time  since  one  of  these  upon  the  palmar  surface  of  the  wrist 
softened  and  became  a  sore,  which  could  not  be  made  to  heal,  and  gradu- 
ally developed  into  its  present  condition  in  spite  of  repeated  efforts  to 
cure  it  by  caustics  and  scraping. 

Such  was  the  history  in  brief  of  the  ulcer.  In  addition,  one  of  the 
warty  formations  between  the  fingers  was  beginning  to  soften,  and  revealed 
on  pressure  a  boggy  consistence.  There  were  also  a  small,  prominent, 
ulcerating  patch  upon  the  inside  of  the  buttock  near  the  anus,  and  two 
small  excoriations  covered  with  crusts  of  doubtful  character  upon  the 
penis  and  in  the  groin,  none  of  which  were  of  long  duration.  The  general 
surface  presented  a  sparsely  scattered  psoriasis  of  guttata  variety.  The 
patient  was  somewhat  feeble  from  the  suffering  caused  by  the  disease  in 
the  palm.  There  was  no  affection  of  the  brachial  glands.  He  was 
advised  to  have  the  diseased  tissue  removed  by  thorough  excision,  and 
for  this  purpose  he  entered  the  Massachusetts  General  Hospital,  under  the 
care  of  Dr.  R.  M.  Hodges,  who  had  seen  the  patient  with  me,  and  recognized 
the  remarkable  identity  of  the  case  with  that  first  reported.  Dr.  Hodges 
has  kindly  prepared  the  following  account  of  its  subsequent  history : 

"The  operation  performed  on  Mr.  ■  's  wrist,  August  18th,  was  an 

excision  of  the  diseased  tissues,  without  regard  to  the  extent  of  surface 
sacrificed,  or  the  depth  or  character  of  the  parts  involved.  This  extent 
represented  superficially  the  area  of  a  circle  two  and  one-eighth  inches  in 
diameter,  and  in  depth  penetrated  to  the  flexor  tendons  and  the  anterior 
surface  of  the  carpal  bones.  The  ulnar  artery  and  nerve,  the  palmaris 
longus  tendon,  portions  of  the  muscles  of  the  thumb  and  of  the  little 
finger,  and  the  anterior  annular  ligament  were  divided  or  removed.  The 
patch  near  the  anus  was  also  dissected  out.  September  12,  a  necrosis  of 
the  tendons  and  fasciae  along  the  ulnar  side  of  the  forearm,  which  had 
slowly  taken  place,  required  an  incision  and  the  removal  of  the  dead 
tissues.  The  healing  processes  following  these  two  operations  having 
been  nearly  completed,  the  patient,  without  apparent  reason,  on  September 
18th,  suffered  sudden  and  extreme  pain  at  the  inner  side  of  the  upper 
arm.  On  the  20th  the  red  lines  of  a  lymphatic  inflammation  were  visible, 
the  axilla  gradually  became  swollen  and  infiltrated  without  any  focal 
centre,  and  a  deep  cellulitis  with  grave  constitutional  symptoms  developed 
itself.  In  spite  of  free  incisions  and  active  supporting  treatment,  the 
patient's  strength  gave  way,  and  on  October  4th  death  occurred  from 
exhaustion.  It  is  needless  to  say  that  from  first  to  last,  the  most  pains- 
taking antiseptic  dressings  were  used."  This  unfortunate  termination 
had,  of  course,  only  an  incidental  connection  with  the  operation,  which 
promised  to  be  as  successful  as  that  in  the  first  case. 

An  examination  of  the  tissues  removed  by  excision  was  made  by  Prof. 
Fitz,  who  furnished  the  following  report :  "  The  specimen  was  character- 
ized by  the  presence  of  large  masses  of  epithelioid  cells  of  irregular  shape 


172 


White,  Psoriasis — Verucca — Epithelioma. 


[Jan. 


and  size,  separated  by  narrow  bands  of  fibrous  tissue,  and  extending  deeply 
downwards  into  the  subcutaneous  fat  tissue.  The  appearance  and  group- 
ing of  the  epithelioid  cells  suggested  that  all  the  epithelial  constituents  of 
the  skin  were  involved,  rete  and  epidermis,  hair  and  sebaceous  follicles, 
likewise  the  sweat  glands.  An  atypical  new  formation,  simulating  the 
last-mentioned  structures,  with  a  central  cavity,  was  abundantly  present 
in  the  main  tumor.  The  smaller  nodule  (from  anal  region)  of  more 
superficial  growth  simulated  in  its  new  formation  rather  the  other  cutane- 
ous structures. 

"  A  comparison  of  the  specimens  from  the  two  cases  showed  a  marked 
difference  of  composition.  That  from  Case  I.  presented  an  abundant, 
dense,  fibrous  stroma,  with  narrow  and  sparse  anastomosing  bands  of  small, 
round  epithelioid  cells.  The  shape,  size,  and  j  unction  of  these  bands  directly 
suggested  the  distribution  of  the  lymph-vessels  of  the  skin.  Indeed,  the 
question  directly  arose,  whether  the  new  growth  may  not  have  affected 
primarily  the  lymphatics,  representing  what  has  been  called  catarrhal 
lymphangitis.  The  specimen  from  Case  II.  showed  an  abundant,  luxu- 
riant growth  of  large  epithelioid  cells  with  but  a  scanty  fibrous  stroma 
between  the  masses.  Epidermoid  pearls  were  numerous  in  the  small 
nodule,  and  cavities  of  considerable  size  with  irregularly  projecting  and 
abundantly  cellular  walls  suggested  the  dilatation,  as  well  as  new  forma- 
tion, of  an  adenoid  structure  resembling  the  sweat-gland." 

[During  the  preparation  of  this  paper  for  the  Society,  I  discovered  in 
Ziemssen's  Handbuch,  Band  xiv.  (Hautkrankheiten),  a  reference  to  a 
case,  the  following  brief  account  of  which  is  published  in  the  Gaz.  des 
Hopit.,  1878,  p.  750.  Dr.  Cartaz  presented  to  the  Anatomical  Society 
the  report  of  a  healthy  man,  40  years  old,  who  had  never  had  any  other 
disease  excepting  a  psoriasis,  which  began  twenty-three  years  previously, 
and  had  invaded  among  other  regions  the  palms  and  soles.  In  conse- 
quence of  scratching,  the  scales  upon  one  of  these  processes,  situated 
upon  the  palmar  surface  of  the  second  phalanx  of  the  ring  finger  of  the 
right  hand,  was  removed,  and  there  remained  a  little  ulceration,  which 
gradually  extended  to  the  size  of  four  centimetres.  The  callous  borders 
and  the  deep-seated  granulations,  bleeding  at  the  slightest  touch,  estab- 
lished the  diagnosis  of  cancroide.  Amputation  at  the  metacarpophalan- 
geal joint  was  performed,  and  there  was  no  return  of  the  disease. 

Although  no  mention  is  made  in  this  very  brief  report  of  the  interme- 
diate formation  of  warty  growths,  there  can  be  no  doubt  at  least  of  the 
close  resemblance  of  the  case  to  those  above  reported  in  the  connection  of 
its  initial  and  final  processes,  probably  none  of  its  complete  identity.] 

We  have  thus  the  record  of  three  cases  of  psoriasis  terminating  in 
carcinoma  of  the  cutaneous  tissues.  There  are  no  peculiarities  in  the 
history  or  character  of  the  primary  dermatosis  in  the  first  two,  at  least, 
to  suggest  even  an  explanation  of  so  rare  and  grave  a  transformation  of 
process.  Innumerable  cases  of  as  long  duration  and  intractable  type 
occur  with  no  such  termination,  and  it  is  unlikely  that  psoriasis  is  capable 


1885.] 


Wendt,  Unilateral  Spasm  of  the  Tongue. 


173 


of  such  a  direct  change.  The  lesson  to  be  drawn  from  their  study  is,  that 
the  transformation  of  patches  of  psoriasis  into  verrucous  hypertrophy 
must  be  regarded  as  an  ominous  occurrence,  and  that  the  softening  or 
other  change  of  such  horny  growths  demand  thorough  excision  without 
delay. 


Article  XV. 

A  Case  of  Unilateral  Spasm  of  the  Tongue.    By  Edmund  C. 
Wendt,  M.D.,  of  New  York. 

Spasm  of  the  tongue,  occurring  as  an  independent  affection,  is  generally 
recognized  to  be  quite  rare.  A  case  of  this  kind  having  recently  fallen 
under  my  notice,  I  thought  it  deserved  to  be  placed  on  record. 

Mr.  U.,  aged  36,  single,  a  native  of  the  United  States,  first  consulted 
me  for  his  present  trouble  in  December,  1883.  He  was  a  medium-sized, 
powerfully  built  man,  of  excellent  physique,  and  fair  mental  capacity. 
His  occupation  of  builder  or  contractor  gave  him  ample  but  not  excessive 
out- door  exercise.  He  was  entirely  free  from  any  hereditary  or  acquired 
taint.  His  past  life  had  been  one  of  moderation  in  all  respects.  He  was 
neither  a  drinker  nor  a  smoker  in  the  usual  sense,  although  he  was  not 
a  total  abstainer.  As  regards  sexual  intercourse,  while  not  claiming  to 
be  absolutely  continent,  he  had  never  felt  much  desire  for  indulgence  of 
that  kind.  He  remembered  no  serious  illness  at  any  period  of  his  life, 
and  save  for  the  trouble  with  his  tongue  and  throat,  considered  himself, 
even  now,  in  perfect  health. 

Regarding  the  ailment  for  which  he  sought  advice,  he  stated  that,  for 
some  weeks  past,  the  right  side  of  his  tongue  would  now  and  then  sud- 
denly get  hard  and  be  thrown  into  contractions.  Such  attacks  would  last 
for  from  one-half  to  several  minutes.  The  intervals  were  quite  free  from 
morbid  manifestations  of  any  kind,  except  a  feeling  of  rawness  or  soreness 
at  and  about  the  right  tonsil.  He  further  said  that  the  lingual  spasm 
would  sometimes  completely  disappear  for  one  or  two  days,  and  at  other 
times  recur  every  few  hours.  He  paid  little  attention  to  it  at  first,  but 
latterly  it  seemed  to  be  gaining  in  intensity  to  such  an  extent  that  it 
interfered  somewhat  with  distinct  articulation.  An  examination  of  his 
throat  and  tongue  revealed  nothing  abnormal,  nor  did  the  rest  of  his  body 
show  any  noteworthy  departure  from  health.  It  should  here  be  stated, 
however,  that  at  a  subsequent  examination  by  a  specialist,  there  was 
found  "  deviation  of  cartilaginous  nasal  septum  to  the  right,  hypertrophy 
of  both  inferior  turbinated  tissues  anteriorly,"  and  some  "  chronic  irrita- 
tive hyperemia  of  the  larynx."    I  use  the  exact  words  of  the  written 


174 


Wendt,  Unilateral  Spasm  of  the  Tongue. 


[Jan. 


report  submitted  to  me  by  the  specialist  to  whom  the  patient  was  referred. 
The  special  senses  in  the  case  of  Mr.  U.  were  normally  acute  ;  and  with 
particular  reference  to  his  tongue,  taste  was  perfect  on  either  side,  as 
appeared  from  repeated  experimental  trials  in  that  direction. 

I  was  unwilling  at  first  to  place  entire  credence  in  the  history  as  fur- 
nished by  the  patient.  For  several  weeks  he  took  arsenic  and  bromides, 
and  used  a  variety  of  gargles  and  mouthwashes.  He  derived  no  benefit 
from  this  treatment,  the  paroxysms  came  as  before,  and  if  not  occurring 
with  increased  violence,  they  were  certainly  not  diminished  either  in 
severity  or  as  regards  the  frequency  of  their  occurrence.  One  day  the 
patient  was  again  in  my  office,  when  he  suddenly  stopped  short  in  his 
speech,  and  opening  his  mouth  pointed  to  the  tongue.  I  then  saw  very 
distinctly  that  organ  drawn  a  little  to  the  right  side,  and  a  succession  of 
rapid  twitchings  that  lasted  but  a  few  moments,  and  presently  culminated 
in  a  well-marked  rigidity  of  the  right  half  of  the  tongue.  The  entire 
phenomenon  lasted  about  one  minute,  and  the  patient  assured  me  that  it 
had  been  a  paroxysm  of  moderate  severity.  Being  now  convinced  that  I 
had  to  deal  with  a  real  motor  disturbance,  affecting  some  of  the  muscles 
supplied  by  the  right  hypoglossal  nerve,  I  determined  to  try  the  galvanic 
current,  especially  as  I  now  felt  quite  sure  that  the  patient  had  spoken 
the  truth  with  regard  to  his  ailment.  Daily  applications  were  made  in 
the  following  manner :  A  medium-sized  sponge-electrode  was  pressed 
rather  firmly  against  the  angle  of  the  jaw,  and  a  ball  electrode,  connected 
with  the  cathode,  was  passed  along  the  right  margin  of  the  tongue.  The 
patient  complained  somewhat  of  an  intensely  metallic  taste  and  a  prickling 
sensation,  but  experienced  no  other  unpleasantness.  The  strength  of  the 
current  never  exceeded  ten  cups  of  the  gravity  battery. 

No  improvement  occurred  until  the  eighth  seance.  Then  Mr.  U.  stated 
that  he  had  noticed  a  decided  change  for  the  better.  This  amelioration 
continued,  and  after  fourteen  sittings  the  spasms  had  completely  left  him. 

It  may  be  premature  to  report  the  case  as  permanently  cured,  since 
only  ten  months  have  passed  since  the  disappearance  of  the  spasm. 
Nevertheless  the  account  just  given  may  be  considered  as  fairly  illus- 
trative of  the  decidedly  beneficial  action  of  galvanism  in  localized  mus- 
cular cramps.  Finally,  I  may  say  that  the  causation  of  this  condition  in 
Mr.  U.'s  case  has  remained  dark  to  me.  I  have  no  theory  to  offer  con- 
cerning it. 

New  York,  102  E.  57th  Street, 
October  22,  1884. 


1885.] 


175 


REVIEWS. 

Art.  XVI. — Recent  Works  on  Practice. 

1.  Lectures  on  the  Principles  and  Practice  of  Medicine,  delivered 

in  Chicago  Medical  College.  By  Nathan  Smith  Davis,  A.M., 
M.D.,  LL.D.,  Dean  of  the  Faculty,  and  Professor  of  Principles  and 
Practice  of  Medicine.  8vo.  pp.  896.  Chicago  :  Jansen,  McClurg 
&  Co.,  1884. 

2.  A  Text-booh  of  Practical  Medicine,  designed  for  the  use  of  Students 

and  Practitioners  of  Medicine.  By  Alfred  L.  Loomis,  M.D., 
LL.D.,  Professor  of  Pathology  and  Practical  Medicine  in  the 
Medical  Department  of  the  University  of  the  City  of  New  York. 
8vo.  pp.  1102.  211  Illustrations.  New  York:  Wm.  Wood  & 
Co.,  1884. 

3.  A  Treatise  on  the  Theory  and  Practice  of  Medicine.    By  John 

Syer  Bristowe,  M.D.,  LL.D.,  F.R.S.,  Fellow  of  the  Royal  Col- 
lege of  Physicians  ;  Senior  Physician  and  Lecturer  on  Medicine  at 
St.  Thomas's  Hospital,  London.  8vo.  pp.  1240.  Fifth  edition. 
London  :  Smith,  Elder  &  Co.,  1884. 

In  a  review,  written  in  1881,  we  remarked  upon  the  paucity  of  Ame- 
rican text-books  of  medicine,  and  upon  the  modesty  of  the  sixty-five 
professors  of  "  Theory  and  Practice,"  who  for  nearly  twenty  years  had 
left  the  field  in  possession  of  foreign  authors,  with  whom  Wood  and  Flint 
alone  competed.  The  example  set  by  Dr.  Bartholow,  in  1881,  was  soon 
followed  by  Dr.  Palmer,  of  Michigan  ;  and  now  we  have  placed  at  the 
head  of  the  list  two  new  candidates  for  professional  favor,  which  we  pro- 
pose to  introduce  to  our  readers. 

1.  One  of  the  motives,  and  we  may  suppose  the  chief  one,  which  has 
induced  Dr.  Davis,  towards  the  close  of  his  professional  life,  to  give  to 
the  world  this  bulky  volume,  "  was,"  as  he  says,  "  a  desire  to  place  on 
record  those  views  and  modes  of  practice  developed  in  my  own  mind  as  a 
result  of  fifty  years'  constant  devotion  to  the  study  and  practice  of  the 
healing  art."  Another  motive,  wrhich  he  mentions,  will  be  less  appre- 
ciated, viz.,  "to  place  within  reach  of  medical  students  a  work  on  practice 
which  embodies  in  its  text  the  metric  system  of  weights  and  measures." 
Fortunately,  to  prevent  embarrassment,  the  equivalents  in  the  old  system 
are  given. 

The  work  consists  of  ninety-two  lectures,  embracing  substantially  the 
course  which  Dr.  Davis  has  been  in  the  habit  of  giving  in  the  Chicago 
Medical  College,  and  prepared  for  publication,  from  stenographic  reports, 
but  in  part  rewritten,  and  all  fully  revised. 

The  first  five  lectures,  upon  the  general  principles  of  medicine,  illus- 
trate the  difficulty  a  teacher  has  in  escaping  from  the  bonds  in  which  a 
routine  course,  delivered  year  after  year,  tends  to  inclose  him.  They 
bear  the  impress  of  the  thoughts  and  professional  opinions  of  thirty 
years  ago — at  which  time,  very  possibly,  the  framework  was  put  together — 


176 


Reviews. 


[Jan. 


and  though  modernized  in  many  respects,  one  is  constantly  reminded,  in 
their  perusal  of  those  fine  old  works  on  Principles  by  Billings,  Williams, 
and  Simon.  In  Lecture  VI.,  under  classification,  we  are  given  a  truly 
extraordinary  arrangement  of  diseases.  The  two  great  divisions  are  made 
into  General  and  Local  affections,  and  the  latter  are  divided  into  four  sub- 
classes, Inflammation,  Fluxes,  Neuroses,  and  Miscellaneous.  The  term 
"  fluxes"  is  stated  to  be  not  free  from  criticism  ;  but  it  is  made  to  do  good 
service,  and  under  it  we  find  the  motley  group  of  diaphoresis  (cutaneous 
flux),  serous  diarrhoea,  epidemic  and  sporadic  cholera,  dropsies,  and 
hemorrhages.  The  miscellaneous  sub-class  is  an  olla  podrida  of  spas- 
modic asthma,  aphonia,  diabetes,  angina  pectoris,  parasites,  etc.  And 
yet  Dr.  Davis  naively  enough  remarks,  in  objecting  to  etiological  or  ana- 
tomical methods  of  classification,  that  they  "  lead  to  the  grouping  together 
of  diseases  the  most  dissimilar  in  their  nature !" 

To  understand  Dr.  Davis's  views  on  fever  we  must  observe  that  he 
recognizes  two  inherent  elementary  properties  of  living  matter,  one  which 
gives  it  the  capacity  to  receive  impressions,  susceptibility,  the  other,  vital 
affinity,  causes  the  atomic  changes,  which  result  from  the  impression,  to 
follow  certain  laws.  Fever  is  not  caused  primarily  by  alteration  of  the 
blood  or  a  depression  of  the  nervous  or  other  processes,  but  "  consists  in 
the  action  of  some  cause  capable  of  disturbing  the  general  elementary 
properties  common  to  all  the  organized  structures,"  i.  e.,  the  susceptibility 
and  vital  affinity.  Thus  in  the  fever  of  pure  excitement,  febricula,  both 
of  these  primary  endowments  of  the  living  tissues  are  increased,  whereas, 
in  the  typhoid  group  they  are  diminished ;  on  the  other  hand,  in  the 
periodical  group,  sensibility  is  increased,  and  vital  affinity  impaired  ;  and 
again,  in  the  eruptive  group  of  fevers,  the  sensibility  is  increased,  and 
the  vital  affinity  perverted. 

The  subject  of  typhoid  fever  is  very  fully  discussed,  and  the  author  is 
strongly  in  favor  of  the  view  that  it  may  arise  spontaneously,  holding 
that  it  may  originate,  first,  in  any  dwellings  in  which,  from  over-crowd- 
ing or  ill-ventilation,  the  air,  furniture,  and  walls  of  the  rooms  become 
impregnated  with  organic  emenations  ;  second,  from  the  percolation 
through  the  soil,  from  drains  or  privies,  of  fecal  and  urinary  matters  ; 
and,  third,  it  may  even  occur  in  an  individual  without  communication 
with  other  cases  or  sources  of  infection,  originating  from  causes  "such 
as  protracted  mental  depression  and  anxiety,  excessive  mental  and  physi- 
cal work,  and  abrupt  changes  from  out-door  to  passive  in-door  work." 
Under  such  circumstances  it  is  possible  that  there  may  be  modifications 
in  the  processes  of  disintegration  of  living  structures,  evolving  septic  or 
other  poisonous  material,  which,  returned  into  the  blood,  produce  febrile 
disturbance  of  the  same  character  as  when  an  organic  poison  is  received 
from  without.  That  the  evidence  for  a  specific  typhoid  germ  has  no 
existence  except  in  the  human  imagination  is  the  burden  of  the  lecture 
on  etiology,  and  a  great  many  interesting  facts  are  adduced  against  the 
more  popular  and  prevalent  theory. 

Dr.  Davis  has  been  very  successful  in  his  treatment  of  the  disease.  Of 
520  cases  treated  by  him  in  the  Mercy  Hospital,  from  1850  to  1880,  only 
1  in  16,  or  6.2  per  cent,  died — a  very  low  mortality  for  a  general  hospital. 
He  attaches  less  importance  to  the  temperature  than  other  writers,  and 
believes  that  the  conditions  of  the  kidneys,  abdominal  viscera,  and  lungs 
offer  more  reliable  guides  in  prognosis.  In  his  remarks  upon  treatment 
there  is  much  of  interest.    In  cachectic  and  depressed  conditions  of  the 


1885.] 


Recent  Works  on  Practice. 


177 


system  he  has  found  more  benefit,  from  the  use  of  small  doses  of  the  bichlo- 
ride of  mercury  with  cinchona  than  from  all  the  preparations  of  iron,  cod- 
liver  oil,  and  alcoholic  stimulants.  In  typhoid  its  use  is  limited  to  the 
early  stage. 

The  use  of  calomel  for  its  specific  curative  effect  in  typhoid,  revived  of 
late  in  Germany,  he  has  seen  in  many  cases,  and  it  was  thoroughly  tried 
and  found  wanting  by  the  physicians  of  the  South  and  West  from  1835  to 
1850.  Dr.  Davis  is  an  unsparing  opponent  of  the  use  of  alcohol  in  the 
disease,  believing  that  it  increases  the  impairment  of  nerve  force,  lessens 
the  interchange  of  carbonic  acid  gas  and  oxygen,  and  thereby  favors  the 
congestion  in  the  lungs  and  other  organs,  and  the  fatty  degeneration  of 
the  heart.  Several  very  interesting  cases  are  given  illustrating  his  change 
of  opinion  on  these  questions.  In  the  prostration  and  low  delirium  he 
relies  upon  careful  feeding  and  the  use  of  strychnia  and  nitric  acid. 

The  lecture  on  yellow  fever  gives  a  full  and  clear  statement  of  our 
knowledge  of  this  affection,  and  the  labors  of  the  Southern  profession  are 
acknowledged  and  utilized. 

In  speaking  of  the  history  of  epidemics  of  erysipelas  in  the  country  Dr. 
Davis  is  able  to  confirm,  from  personal  observation,  the  truth  of  the  state- 
ment, that  the  epidemic  of  1841—46  was  true  erysipelas,  and  not  "an 
acute  infectious  disease  closely  allied  to  diphtheria,"  as  supposed  by  Hirsch 
and  Zuelzer. 

The  important  subject  of  the  periodical  fevers  is  discussed  in  three  lec- 
tures. In  the  severe,  congestive  types  the  author  strongly  urges  the  use 
of  the  cold  douche  for  the  purpose  of  establishing  a  reaction.  The  author 
does  not  think  that  there  is  a  distinct  typho-malarial  fever,  but  simply  an 
intermingling  of  the  symptoms  and  pathological  changes  in  patients  dwelling 
in  localities  in  which  the  causes  of  both  continued  and  intermittent  fevers 
are  prevalent. 

Under  local  affections,  inflammation  is  first  considered,  and  here  the 
author's  two  elementary  properties  of  the  tissues  do  good  service  in  the 
analysis  of  the  phenomena.  In  the  three  forms — sthenic,  asthenic,  and 
specific — the  susceptibility  of  structure  is  exalted,  and  the  quantity  of 
blood  increased.  In  sthenic  the  vital  affinity  is  increased,  and  the  quality 
of  the  blood  plastic  ;  in  the  asthenic  form  it  is  just  the  reverse,  while  in 
the  specific  the  vital  affinity  is  perverted,  and  the  quality  of  the  blood 
toxaemic.  The  process  is  thus  explained  in  a  simple  manner,  but  by 
making  very  free  use  of  properties,  upon  the  nature  of  which,  we  are  told, 
it  would  be  a  waste  of  time  to  speculate.  We  are  given  a  lamp  with 
which  everything  shall  be  made  clear  and  bright,  but  with  neither  oil  nor 
wick  nor  match. 

We  turned  with  interest  to  the  lectures  on  pneumonia  to  find  things 
new  and  old,  which  Dr.  Davis  has  brought  out  of  his  treasures  of  knowl- 
edge. He  shows  pretty  clearly  that  the  disease  prevails  more  extensively 
in  the  Middle  and  Northern  States  than  in  the  Southern,  as  held  by 
Drake  and  some  recent  writers.  The  disease  is  regarded  as  an  acute  local 
inflammation,  not  a  general  febrile  disease,  and  there  is  no  evidence  of  a 
specific  poison,  organic  or  inorganic.  Typhoidal  and  malarial  influences 
as  modifying  the  type  are  considered.  A  form  of  rheumatic  pneumonia 
is  also  described,  but  on  very  insufficient  grounds.  In  the  case  which  is 
quoted  in  illustration,  the  man  had  during  the  attack  severe  and  persistent 
pain  in  the  chest,  endocarditis  developed,  and  he  died  in  about  two  weeks. 
The  presence  of  these  symptoms,  and  the  fact  that  the  patient  had  had 
No.  CLXXVII  Jan.  1885.  12 


178 


Reviews. 


[Jan. 


occasional  attacks  of  articular  rheumatism,  led  to  the  opinion  that  he  had 
"subacute  rheumatic  inflammation  of  the  parenchyma  of  the  lung;  in 
other  words,  genuine  rheumatic  pneumonia."  Gouty  and  syphilitic  forms 
of  the  disease  might  readily  be  described  on  equally  good  grounds. 

The  author's  experience  in  the  treatment  is  instructive.  When  he 
began  practice  in  a  country  district  in  1837  he  bled  and  gave  tartar 
emetic,  and  found  that  the  sthenic  cases  did  well  on  this  plan.  In  his 
early  days  in  Chicago,  when  malaria  was  prevalent,  quinine  was  most 
useful,  and  bleeding,  except  in  rare  cases,  of  no  utility.  In  the  heart 
failure,  which  he  does  not  look  upon  as  induced  so  much  by  the  fever  as 
by  the  defective  oxygenation,  he  finds  the  stimulating  effects  of  quinine, 
digitalis,  and  chlorate  of  potash,  with  coffee,  the  most  valuable  remedies 
which  have  succeeded  in  his  hands  when  alcohol  has  failed. 

Three  forms  of  phthisis  are  recognized :  tuberculous,  pneumonic,  and 
fibroid.  The  question  of  the  contagiousness  is  not  discussed,  and  the 
bacillus  is  believed  to  be  only  an  accompaniment  of  the  degenerative 
changes  in  the  tubercular  masses  and  without  causative  influence.  Even 
its  diagnostic  value  is  doubted. 

The  lectures  on  the  nervous  system  suffer  from  the  system  of  classifi- 
cation which  the  author  has  adopted.  Meningitis,  cerebral  and  spinal 
sclerosis,  come,  early  in  the  work,  under  local  inflammations  ;  while  apo- 
plexy, hemiplegia,  paraplegia,  chorea,  etc.  come  late  in  the  sub-class 
neuroses.  The  large  amount  of  good  work  which  has  been  done  of  late 
in  this  department,  and  which  has  rendered  the  study  of  nervous  diseases 
so  much  more  simple,  has  not  been  utilized  to  a  sufficient  extent. 

Lectures  82  and  83  on  insanity,  while  pleasant  reading,  are  too  dis- 
cursive, and  do  not  show  an  acquaintance  with  modern  psychological  medi- 
cine. They  should  be  dropped  from  a  subsequent  edition,  and  the  pages 
allotted  to  a  specialist.  It  is  difficult  to  understand  the  omission  of  the 
subject  of  general  paresis,  so  important  to  the  ordinary  practitioner. 

Dr.  Davis's  therapeutics  are  most  consoling  in  these  days  of  general 
scepticism.  Art  with  him  is  everything  ;  Nature  as  understood  by  Holmes 
and  others  "  not  merely  a  fanciful  goddess,  but  a  positive  hindrance  to  the 
advancement  of  practical  medicine."  We  have  already  given  some 
illustration,  but  will  briefly  refer  to  one  or  two  others.  Mercury  holds  a 
high  place  in  his  estimation,  if  one  may  judge  from  the  number  of  times 
its  use  is  advised  in  various  diseases.  The  index  contains  eighty-three 
references  to  its  employment.  In  hard  cancer  some  very  remarkable 
statements  are  made  of  the  power  of  the  bichloride  to  arrest  the  growth 
when  combined  with  a  simple  milk  and  vegetable  diet.  Except  in  cases 
of  cancer  of  the  stomach  he  has  never  seen  this  treatment  fail  to  relieve 
the  pain  and  check  the  growth.  On  the  question  of  the  use  of  alcohol 
Dr.  Davis  is  clear  and  emphatic,  and  if  his  opinions  prevail  with  the  staff 
of  the  Mercy  Hospital,  the  item  of  "  wine  and  spirits"  in  the  annual 
account  must  be  very  small.  He  holds  that  from  first  to  last  it  acts  as  a 
paralyzarit  and  anaesthetic,  and  is  in  no  sense  a  stimulant.  As  a  result 
of  thirty-five  years'  clinical  study  of  the  effects  of  alcohol  in  all  forms  of 
low  febrile  diseases,  he  has  never  yet  found  an  instance  in  which  it  in- 
creased the  cardiac  force  or  the  efficiency  of  the  circulation.  Place  this 
negative  statement  against  the  very  positive  assertions  of  so  many  other 
observers,  and  we  have  an  illustration  of  how  difficult  it  is  to  get  at  thera- 
peutical truth,  and  how  much  must  be  allowed  for  the  "  personal  equation" 
in  the  observer. 


1885.] 


Recent  Works  on  Practice. 


179 


The  work  as  a  whole  is  strongly  conservative  in  its  tendencies  ;  the 
younger  men  "  whose  apprehensive  senses  all  but  new  things  disdain"  will 
call  it  old-fashioned,  but  they  will  find  in  its  pages  the  ripe  wisdom  of  a 
keen  and  conscientious  observer  who  has  arrived  at  conclusions  after  study 
and  deliberation,  conclusions  from  which  at  times  we  may  differ,  but  which 
deserve  our  consideration  and  respect. 

In  one  matter  the  work  is  the  most  distinctively  American  practice 
which  we  have.  From  his  long  connection  with  the  American  Medical 
Association  and  with  American  journalism,  Dr.  Davis  has  become 
thoroughly  familiar  with  the  good  work  done  year  after  year  by  men  who, 
far  from  the  great  centres,  have  placed  their  contributions  in  local  Journals 
and  the  Transactions  of  State  Societies,  from  the  quiet  solitudes  of 
which  he  has  in  many  instances  gleaned  most  useful  information,  and 
the  work  abounds  with  references  to  the  communications  of  men  in  every 
section  of  the  country. 

It  has  been  said  that  the  climate  of  Chicago  is  unfavorable  to  careful 
proof-reading.  We  do  not  wish  to  be  too  critical,  but  there  are  2^  few  errors 
which  spoil  one's  pleasure  in  reading.  The  proper  names,  particularly  of 
foreigners,  need  revising.  At  p.  28  the  average  temperature  of  the  body 
is  given  as  55°  C.  (78.G°F.).  One  of  the  most  curious  errors  is  at  p.  843, 
where  the  words  "  frematoid  or  fluted  worms"  are  used  instead  of  trema- 
toid  worms  or  flukes. 

The  index  is  a  striking  example  of  how  such  a  valuable  adjunct  to  a 
book  should  not  be  prepared.  It  is  largely  an  index  of  authors'  names 
and  therapeutic  means.  Thus,  under  the  letter  B,  of  fifty-three  references, 
only  three  are  to  diseases,  and  under  brain,  only  one  reference  is  given, 
inflammation  of.  The  fevers  are  all  grouped  under  the  word  fever, 
without  any  other  references  to  special  forms. 

2.  The  work  of  Dr.  Loomis  is  in  many  respects  a  great  contrast.  It,  too, 
is  a  revision  and  elaboration  of  the  lectures  on  Medicine  given  at  the 
University  of  New  York,  but  we  miss  in  it  the  special  features  which 
make  Dr.  Davis's  lectures  so  valuable.  We  do  not  feel  the  author's 
personality  so  strongly,  which  is  of  course  not  to  be  expected  ;  and  the 
work  is  more  like  the  general  run  of  text-books  on  the  subject,  and  in  so 
being  has  more  than  compensating  advantages  as  a  manual  for  studen  s. 
It  is  systematic ;  the  lecture  form  has  been  obliterated ;  it  is  well 
arranged  and  fully  illustrated. 

An  introduction  of  eight  pages,  on  Inflammation,  opens  the  work,  and 
the  diseases  of  the  respiratory  system  are  at  once  considered.  Croup  is 
regarded  as  a  distinct  disease,  and  the  characteristic  differences  which  are 
given  certainly  serve  to  distinguish  it  from  diphtheria. 

The  prevalence  of  pneumonia  is  stated  to  increase  from  the  pole  to  the 
equator,  and  is  more  common  in  the  Southern  than  in  the  Northern  States, 
an  opinion  which,  as  we  noted,  is  opposed  to  Dr.  Davis's  observation  and 
research.  In  the  compass  of  a  page  a  very  strong  case  is  put  in  favor  of 
the  view  that  it  is  an  acute  specific  disease.  In  its  treatment  Dr.  Loomis 
recommends,  as  the  result  of  the  past  five  years'*  experience,  that  the 
patient  be  brought  under  the  full  influence  of  opium,  and  held  in  a  state 
of  comparative  comfort  by  repeated  hypodermic  injections.  In  this  way 
the  primary  shock  is  well  sustained,  and  the  chance  of  heart  failure  is 
lessened.  The  relief  and  comfort  which  it  gives  are  sufficient  to  commend 
its  use.    The  drug  should  be  stopped  as  soon  as  the  infiltration  is  com- 


180 


Reviews. 


[Jan. 


pleted.  For  cardiac  failure,  alcohol  is  given  the  first  place,  and  to  reduce 
high  temperature,  quinine  in  doses  from  grs.  x  to  xv  is  preferred  to 
cold.  In  his  treatment  of  the  disease  Dr.  Loomis  occupies  a  mid-position 
between  Dr.  Davis  with  his  poly-pharmacy  and  Dr.  Bristowe  with 
"  nature  and  nurse."  It  is  most  instructive  to  read  the  sections  on  the 
treatment  of  this  disease  in  these  three  works.  Dr.  Bristowe,  in  a  little 
more  than  a  page  full  of  qualifying  phrases,  such  as,  "  may  possibly," 
"  probably,"  "  perhaps,"  as  regards  drugs,  gives  most  rational  advice,  and, 
while  treating  ordinary  cases  expectantly,  he  is  in  many  quite  prepared  to 
supplement  this  plan  by  other  measures.  Alcohol  he  also  regards  as 
indispensable  in  certain  cases. 

In  the  treatment  of  empyema  Dr.  Loomis  gives  very  clear  warning 
against  washing  out  the  cavity,  and  his  recent  experience  is  very  posi- 
tively against  it,  having  on  three  occasions  had  reason  to  believe  that 
death  followed  the  injection  of  weak  carbolic  acid  solutions. 

The  author's  position  on  the  relation  of  the  bacillus  to  tubercle  is  put  as 
follows:  "  The  presence  of  a  distinct  bacillus  in  connection  with  tubercle, 
and  its  absence  in  all  other  morbid  conditions,  are  generally  confirmed  by 
the  most  competent  observers.  The  etiological  relation  of  this  bacillus  to 
phthisis  rests  solely  on  the  demonstration  of  Koch.  Observers  are  not  want- 
ing who  deny  entirely,  not  only  the  etiological  relation,  but  even  that  this 
bacillus  is  confined  to  the  tubercular  tissues — but  they  fail  to  present  satis- 
factory proof  of  such  statements."  The  question  of  the  contagiousness  he 
holds  is  one  to  which  clinical  observation  has  given  no  conclusive  answer. 
In  the  treatment  of  phthisis  the  author  places  great  confidence  in  quinine, 
believing  that  no  drug  has  equal  power  of  arresting  phthisical  processes 
in  the  early  stage. 

In  the  section  on  Diseases  of  the  Digestive  System  and  Diseases  of  the 
Heart,  we  notice  nothing  for  special  comment;  they  are  carefully  pre- 
pared and  well  illustrated. 

In  the  treatment  of  uraemia  the  use  of  morphia  is  strongly  recommended 
to  arrest  the  spasms,  induce  sweating,  and  facilitate  the  action  of  cathar- 
tics and  diuretics.  The  arterio-capillary  fibrosis  of  Gull  and  Sutton  is 
recognized  as  a  tolerably  well-defined  disease,  characterized  by  hyaline- 
fibroid  changes  in  the  arterioles  and  atrophy  of  the  adjacent  tissues,  and 
clinically  by  a  state  of  high  arterial  tension.  The  vascular  changes  are 
primary,  the  renal  and  cardiac  secondary. 

Typhoid  fever  is  regarded  as  a  miasmatic  contagious  disease,  the  specific 
poison  of  which  is  in  the  fecal  discharges,  but  is  not  active  when  these  are 
fresh,  requiring  to  undergo  a  development  outside  of  the  body,  either  in 
the  excrement  itself,  or  in  soil  saturated  with  it.  In  the  treatment  of  the 
fever  the  cold  bath  is  favorably  spoken  of,  when  employed  with  care  and 
judgment.  In  the  majority  of  cases  the  temperature  can  be  kept  below 
103°  by  quinine,  but  there  are  some  which  require  the  cold  bath  as  well. 
In  such  cases  Dr.  Loomis's  rule  is  :  after  reducing  the  temperature  to  101° 
or  102°  F.  by  a  cold  bath,  to  administer  an  antipyrectic  dose  of  quinine, 
and  thus  delay  the  recurring  rise.  The  whole  subject  of  the  treatment  of 
this  important  disease  and  its  complications  is  most  carefully  and  judicially 
considered. 

In  typhus  fever  the  author  speaks  most  strongly  of  the  value  of  fresh 
air  in  neutralizing  the  poison,  and  advises  the  use  of  tents  in  every  epi- 
demic. He  urges  caution  in  the  employment  of  alcohol,  and  gives  an 
exceedingly  interesting  account  of  the  fever  tents  of  Black  well's  Island 


1885.] 


Recent  Works  on  Practice. 


181 


in  1864,  where  the  use  of  stimulants  was  reduced  to  a  minimum,  and  yet 
the  death-rate  was  only  1  in  16  against  1  in  5  at  Belle vue  Hospital. 

Under  the  term  "continued  malarial  fever,"  there  is  a  very  full  account 
of  the  much-discussed  "  typho-malarial  fever."  It  is  believed  to  be  the 
result  of  the  presence  in  the  body  of  malaria  and  a  septic  poison,  and  in 
its  morbid  anatomy  and  symptomatology  is  a  combination  of  the  two  dis- 
eases. In  cities  where  malaria  prevails  sewer-gases  seem  to  furnish  the 
septic  element  which  is  so  essential  for  its  development.  We  gather  that 
Dr.  Loomis  does  not  believe  that  the  septic  element  is  actually  the  typhoid 
poison,  although  the  intestinal  lesions  which  he  describes  are  almost 
identical  with  those  of  enteric  fever. 

The  article  on  acute  rheumatism  is  very  brief ;  the  complications  are 
simply  referred  to,  and  the  section  on  the  whole  is  disappointing.  The 
author  has  given  up  the  use  of  the  salicylates,  believing  that  they  cause 
depression  of  the  heart,  increase  the  liability  to  endocardial  mischief,  and 
promote  relapses.  He  now  gives  carbonate  of  soda  to  neutralize  the  urine, 
and  morphia  hypodermically  to  relieve  the  pain. 

The  concluding  section  on  Diseases  of  the  Nervous  System  contains  a 
brief,  but  good  summary  of  all  the  more  important  affections. 

The  author  has  produced  a  clear,  practical,  and  useful  text-book,  one 
which  can  be  recommended  to  the  student  as  a  good  companion  in  his 
hospital  work,  and  to  the  busy  practitioner  as  a  safe  guide  in  diagnosis 
and  treatment.  The  illustrations  are  for  the  great  part  original,  and  well 
executed ;  the  execution  of  some  of  the  cuts  is  very  good,  of  many  others 
rather  indifferent.  The  work  is  very  free  from  typographical  errors. 
There  is  one  little  mistake,  due  no  doubt  to  a  slip  of  the  pen,  and  it  re- 
minds us  of  the  remark  of  a  student  who  had  just  come  from  a  clinic 
of  Sir  William's,  at  University  College  Hospital,  London.  "  Why  !"  said 
he,  "  Jenner  is  not  such  an  old  fellow  after  all.  I  thought  vaccination  was 
discovered  years  ago."  Dr.  Loomis  has  written  Sir  William  Jenner,  in- 
stead of  Edward.  The  Gloucestershire  physician  had  tardy  public  and 
professional,  never  court  recognition,  and  his  reputation  is  now,  as  his 
merit  was  then,  above  titular  distinction. 

3.  Dr.  Bristowe's  work  needs  no  words  of  commendation  from  us. 
The  profession  in  Great  Britain  has  endorsed  its  reputation  by  calling  for 
five  editions  within  seven  years.  The  present  differs  from  the  fourth 
chiefly  in  the  incorporation  of  recent  views  on  infective  organisms,  and  in 
a  new  introduction  to  the  section  on  diseases  of  the  heart.  While  to  many 
an  objection  to  this  work  is  in  the  scanty  details  of  treatment,  yet  there  is 
much  force  in  what  the  author  says  in  the  preface,  that  a  man  is  more 
likely  to  make  a  thoughtful  physician  and  benefit  his  patient  by  adapting 
drugs  and  methods  to  the  exigencies  of  cases,  than  by  following  "  the 
stereotyped  procedure  of  some  predecessor."  He  hesitates — many  do  not — . 
to  force  his  "own  routine  and  trivialities  of  practice  upon  students,"  and 
contents  himself  with  inculcating  general  principles,  "  and  pointing  out 
the  specific  virtues  of  certain  drugs."  W.  0. 


182 


Reviews. 


[Jan. 


Art.  XVII.  —  Malaria  and  Malarial  Diseases.  By  George  M. 
Sternberg,  M.D.,  F.R.M.S.,  Major  and  Surgeon  U.  S.  Army;  Mem- 
ber of  the  Biological  Society  of  Washington  ;  late  Member  of  the 
Havana  Yellow  Fever  Commission  of  the  National  Board  of  Health  ; 
Corresponding  Member  of  the  Epidemiological  Society  of  London,  etc. 
8vo.,  pp.  329.    New  York  :  William  Wood  &  Co.,  1884. 

This  volume,  announced  last  year,  was  published  some  time  during 
the  summer.  It  was  looked  for  with  much  interest  by  practical  physicians 
both  in  civil  and  military  circles,  and  proves  to  be,  as  was  expected,  a 
work  of  considerable  interest  and  value.  Coming  to  us  fresh  from  the 
hands  of  its  distinguished  author,  it  arouses  an  interest  that  some  of  the 
volumes  of  the  series  to  Munich  it  belongs  have  failed  to  excite.  The  sub- 
ject is  one  in  which  Dr.  Sternberg  is  known  to  have  long  been  deeply 
interested,  and  while,  as  we  learn  from  the  preface  and  the  text,  he  fully 
recognizes  that  the  unsolved  problems  Connected  with  it  are  not  likely  to 
be  settled  by  the  pen,  its  preparation  has  afforded  him  a  favorable  oppor- 
tunity to  review  the  literature  of  the  subject,  and  to  compare  the  recorded 
experience  of  recent  foreign  authors,  whose  works  have  not  been  repub- 
lished in  this  country,  with  that  of  physicians  in  the  malarious  sections  of 
the  United  States.  Graceful  acknowledgment  to  the  authors  from  whose 
experience  he  has  drawn,  is  made  in  the  preface,  and  precise  biblio- 
graphical references  are  subscribed  at  the  foot  of  almost  every  page.  In 
truth,  every  page  bears  testimony  to  the  discriminating  industry  with 
which  the  author  has  searched  the  older  and  the  recent  writings  upon  the 
subject.  But  the  evidence  of  his  own  extensive  practical  knowledge  is 
no  less  ample,  and  that  which  he  has  to  say  is  interwoven  with  that  which 
he  has  quoted  from  the  writings  of  others,  with  a  deftness  that  does  credit 
alike  to  his  scientific  acumen  and  his  literary  skill. 

The  word  malaria  is  not  used  in  its  etymological  sense  as  a  general 
term  to  include  all  kinds  of  bad  air,  or  even  all  forms  of  disease-producing 
bad  air.  It  is  used  in  the  much  more  restrictive  sense,  as  denoting  "a 
special  kind  of  poison,  not  necessarily  aeriform,  which  produces  certain 
well-defined  morbid  phenomena,  namely,  the  periodic  fevers."  This  test 
of  malaria,  the  author  strongly  insists  upon — that  it  is  known  by  its  effect 
in  causing  the  periodic  fevers.  It  is  certainly  true  that  an  intermittent 
or  remittent  pyrexia  cannot  be  taken  by  itself  as  evidence  of  malarial 
poisoning;  not  even  the  curative  power  of  the  cinchona  alkaloids  can  be 
accepted  as  an  absolute  test ;  nevertheless,  there  is  no  difficulty  in  recog- 
nizing typical  intermittent  fever,  in  which  a  well-marked  paroxysm  occurs 
daily  or  every  second  day  ;  and  the  prevalence  of  this  form  of  fever,  at 
least  during  certain  seasons  of  the  year,  must  be  accepted  as  the  test  of 
the  presence  of  malaria,  in  any  particular  region. 

Dr.  Sternberg  strongly  inclines  to  the  opinion,  which  we  hold  with 
him,  that  the  kind  of  malaria  under  consideration  does  not  produce  other 
forms  of  fever,  and  especially  continued  forms,  not  curable  by  quinine. 
The  truth  of  this  opinion  is  a  matter  of  very  serious  importance  to  general 
medical  knowledge,  and  a  failure  to  recognize  it  has  been  the  cause  of  end- 
less confusion  of  thought,  vagueness  of  teaching,  vitiation  of  statistics, 
and  mistaken  medication.  It  is  open  to  question  whether  an  ephemeral 
fever  (febricula)  is  ever  an  intermittent  of  a  single  paroxysm — a  fever 
due  to  malaria.    Such  ephemeral  fevers  occur  in  non-malarious  regions 


1885.] 


Sternberg,  Malaria  and  Malarial  Diseases. 


183 


om  a  variety  of  causes.  In  malarious  districts  it  is,  however,  the 
fashion  to  attribute  every  case  of  ephemeral  fever  to  malaria. 

The  author  questions  the  propriety  of  ascribing  the  continued  fevers  of 
warm  latitudes,  known  as  acclimating  fevers,  to  malaria.  He  seeks  also 
to/establish,  and  with  success  we  believe,  that  neither  so-called  continued 
remittent  fever,  nor  the  idio- malarial  fever  of  Edward  Miller,  nor  Naples 
fever,  nor  Roman  fever,  nor  Malta  fever,  nor  Rock  fever,  nor  mountain 
fever,  nor  other  not  truly  periodical  local  fevers,  which  have  commonly 
been  attributed  to  malaria,  are  in  fact  due  to  that  cause.  Some  of  them 
are  clearly  due  to  the  poison  which  causes  enteric  fever,  others  to  causes 
not  yet  well  worked  out,  but  malarious,  in  the  sense  in  which  Dr.  Stern- 
berg used  that  term,  they  certainly  are  not.  He  also  emphasizes  the  fact 
that  the  endemic  continued  fevers  of  the  United  States,  which  are  often 
wrongly  attributed  to  malaria,  are  in  reality,  in  many  instances,  atypical 
or  imperfectly  developed  forms  of  enteric  fever. 

With  reference  to  "  typho-malarial"  fever,  Dr.  Sternberg  is  not  satis- 
fied (we  think  the  expression  might  be  stronger)  that  intermediate  forms 
exist  between  periodic  and  enteric  fevers. 

Part  I.  treats  of  malaria, 
i  Malaria  is  defined  as  "  an  unknown  poison,  of  telluric  origin,  the  cause 
of  the  periodic  fevers."  The  mode  of  infection  or  of  intoxication  is  briefly, 
but  clearly  discussed.  The  author  is  unwilling  to  concede,  at  the  outset, 
that  in  the  cause  of  the  periodic  fevers  we  have  to  deal  with  a  living  germ 
capable  of  reproducing  itself  outside  the  body,  and  that  those  diseases  fall 
under  the  head  of  the  "miasmatic  infectious"  diseases  of  Leibermeister. 
He  prefers  to  regard  the  manner  of  the  action  of  the  cause,  whether  by 
"infection"  or  by  "intoxication,"  as  unsettled. 

The  chapter  on  "Speculations  and  Researches  relating  to  the  Nature  of 
Malaria,"  is  written  in  a  truly  scientific  spirit.  The  older  authorities 
concurred  in  confessing  ignorance  of  the  definite  chemical  and  physical 
characters  of  malaria.  The  author  regrets  that  he  does  not  find  himself 
in  a  position  to  give  a  more  definite  answer  to  the  question,  What  is 
malaria?  He  regards  it,  however,  as  right  to  review  the  researches  thus 
far  made,  and  the  speculations  that  have  led  to  them,  in  order  to  indicate 
the  direction  which  future  investigations  should  take. 

Until  recently  the  opinion  commonly  held  was  that  of  Lancisi,  namely, 
that  the  malarial  poison  was  of  a  gaseous  or  aeriform  nature.  Of  late, 
however,  there  has  been  a  growing  disposition  to  believe  that  it  is  parti- 
culate and  organized  ;  in  other  words,  a  living  "  germ"  or  micro-organism. 
This  view  is  not  new.  It  was  formulated  by  Lucretius  (95  B.  C).  The 
author  has  overlooked  the  following  passage  in  the  writings  of  M.  Teren- 
tius  Varro,  a  contemporary  of  Lucretius  (116-27  B.  C),  which  likewise 
formulates  this  view  with  singular  distinctness  :  "  Si  qua  erunt  loca  palus- 
tria  crescunt  animalia  qucedam  jninuta,  qum  non  possunt  oculi  consequi, 
et  per  aera  intus  in  corpus  per  os  et  nares  perveniunt  atque  efficiunt  dif- 
jiciles  morbos.'''' 

In  modern  times  Linnaeus  (1778)  and  J.  K.  Mitchell  (1859)  gave 
prominence  to  this  theory  of  the  causation  of  the  periodic  fevers.  It  is 
hardly  worth  while  to  combat  the  view  that  malarial  fevers  are  produced 
by  gases  well  known  to  chemists,  the  toxic  properties  of  which  are  quite 
different  from  those  exhibited  by  the  unknown  agent  malaria.  But  with 
reference  to  the  suggestion  that  malaria  may  be  some  complex  nitrogenous 
substance  present  in  the  air  of  marshes  and  other  malarious  localities, 


184 


Reviews  . 


[Jan. 


some  outcome  of  the  vital  activity  of  micro-organisms,  the  pabulum  for  the 
rapid  multiplication  of  which  may  exist  in  the  organic  matter  of  malarial 
soils, — with  regard  to  this  suggestion  the  author  cannot  speak  with  the 
same  confidence.  In  sepsin,  the  ptomaines  and  the  proteids  obtained  by 
Weir  Mitchell  and  Reichert  from  serpent  venom,  we  have  examples  ^of 
such  substances  capable  of  producing  the  most  violent  toxic  effects  in  very 
small  doses.  The  theory  of  Bence-Jones  of  the  mode  of  infection  and 
pathogenic  action,  based  upon  the  supposition  that  malaria  is  a  poison  of 
this  kind,  is  not  accepted,  its  weak  point  being  that  "  during  the  remission 
probably  the  poison  is  reproduced  until  sufficient  is  formed,  in  from  one  to 
three  days,  to  go  through  the  same  action  again." 
Dr.  Sternberg  suggests  two  other  explanations  : — 

' '  First.  Malarial  poisoning  may  be  an  intoxication  in  which  the  toxic  agent 
is  not  reproduced  within  the  body,  and  in  which  the  paroxysmal  febrile  attacks 
are  secondary  phenomena,  resulting  remotely  from  injury  to  the  nervous  system, 
caused  by  the  direct  action  of  the  poison,  and  immediately  from  a  secondary 
cause,  such  as  chill,  indigestion,  vitiated  secretion,  etc." 

"  Second.  The  poison  may  be  reproduced  within  the  body  by  the  same  micro- 
organisms which  are  concerned  in  its  production  in  the  soil,  and  which  may  gain 
entrance  to  the  body  by  the  respiration  of  atmospheres  in  which  they  are  sus- 
pended, or  by  the  ingestion  of  malarious  waters." 

Still  another  hypothesis  is  that  malarial  poisoning  results  from  infection 
by  low  organisms,  present  in  a  malarious  atmosphere,  which  directly 
produce  the  phenomena  ascribed  to  malaria,  but  which  do  not  multiply 
within  the  body  of  the  infected  individual. 

Finally,  the  malarial  poison  is  supposed  by  many  to  be  a  living  germ, 
capable  of  self-multiplication  within  the  body  of  an  infected  individual,  as 
well  as  in  the  malarious  soils,  which  are  its  normal  habitat.  According 
to  this  view,  the  morbid  phenomena  are  accounted  for  by  the  direct  action 
of  the  malarial  parasite,  and  the  periodicity  which  characterizes  malarial 
fevers  is  supposed  to  result  from  circumstances  relating  to  the  life-cycle 
and  periodic  development  of  this  micro-organism. 

Dr.  Sternberg  considers  the  observations  and  experimental  researches 
bearing  upon  the  two  last-named  hypotheses  with  great  carefulness  and 
fairness.    He  then  seeks  to  estimate  their  value. 

The  researches  of  Salisbury  (1866),  Bolestra  (1870),  Lanzi  (1876), 
Eklund  (1878),  Klebs  and  Tommasi-Crudeli  (1879),  the  author's  experi- 
ments bearing  upon  the  work  of  the  last-named  observers,  conducted  under 
the  auspices  of  the  National  Board  of  Health,  the  labors  of  Marchia- 
fava,  Cuboni,  Peroncito,  Ceri,  and  others,  finally  the  results  of  the  inves- 
tigations of  Laveran  (1881)  and  Richard  (1882),  in  France,  are  described 
and  critically  examined.  The  difficulties  attending  such  investigations 
are  indicated  ;  the  extreme  liability  of  making  pseudo  discoveries,  and  the 
consequent  importance  of  special  scientific  training  and  of  a  truly  conser- 
vative spirit  on  the  part  of  the  investigator,  are  pointed  out  and  urged 
upon  the  attention  of  the  reader. 

The  circumstances  relating  to  the  production  of  malaria  give  very 
strong  support  to  the  belief  that  the  poison  which  is  produced  in  the  soil — 
in  the  presence  of  organic  matter,  ground-water  and  ground-air,  and 
under  the  influence  of  an  elevated  temperature — is  a  living  organism  or  a 
chemical  product  evolved  during  the  active  growth  of  such  an  organism. 
This  being  admitted,  the  following  possibilities  present  themselves  for  con- 
sideration : — 


1885.]  Sternberg,  Malaria  and  Malarial  Diseases. 


185 


(a)  Malarial  poisoning  may  be  an  intoxication  resulting  from  the  respiration  ot 
an  atmosphere  containing  a  toxic  agent  produced  by  living  organisms  in  the 
soil. 

(b)  It  may  be  an  infection  resulting  from  the  respiration  of  an  atmosphere 
charged  with  malarial  germs,  born  in  the  soil,  which  enter  the  circulation  and 
multiply  in  the  blood,  or  in  special  organs,  and  produce  directly  the  morbid  phe- 
nomena which  characterize  malarial  diseases. 

(c)  Malarial  intoxication  may  result  from  infection  by  malarial  germs,  born  in 
the  soil,  which  multiply  within  the  body  of  the  infected  individual,  and  thus  pro- 
duce a  toxic  chemical  agent  to  which  the  morbid  phenomena  are  due. 

In  this  case  it  is  not  necessary  to  suppose  that  the  malarial  parasite  invades  the 
blood.  It  may  remain  in  the  alimentary  canal,  where  it  would  find  abundant 
pabulum  in  the  food  ingested,  and  where  the  poisonous  products  would  during 
the  active  growth  find  ready  access,  by  absorption,  to  the  circulating  fluid. 

The  second  (b)  of  these  hypotheses,  that  urged  by  Tommasi-Crudeli, 
and  the  believers  in  the  Bacillus  malaria;,  is  that  which  has  of  late  re- 
ceived the  greatest  consideration  ;  but  it  seems  to  the  author  to  have  less 
in  its  favor  than  either  of  the  others.  He  regards  the  third  (c)  with  the 
greatest  favor,  and  points  out  that  it  is  especially  worthy  of  the  attention 
of  future  investigators. 

This  part  of  the  book  is  written  in  a  spirit  of  judicial  impartiality,  too 
rare  in  current  medical  literature.  Aside  from  its  value  as  a  summary 
and  criticism  of  conflicting  views  upon  an  obscure  subject  of  the  most 
general  and  absorbing  interest,  it  is  admirable  as  a  model  of  the  manner  in 
which  the  facts  bearing  upon  unsettled  scientific  inquiries  should  be  pre- 
sented in  literary  review,  and  as  such  we  venture  to  urge  it  upon  the  at- 
tention of  investigators,  both  in  the  laboratory  and  at  the  bedside.  The 
facts  upon  which  an  hypothesis  is  based  should  be  sifted  with  the  mind  of 
the  judge,  rather  than  colored  by  the  fancy  of  an  advocate,  before  they 
are  adduced  as  evidence.  Certainly  they  should  be  able  to  stand  close 
scrutiny  as  to  their  veritableness,  relevancy,  and  common  interdepen- 
dence. 

The  general  effects  of  malaria  are  next  considered,  and  then  the  anti- 
dotes to  malarial  poisoning  and  prophylaxis.  The  chapter  on  general 
distribution  is  a  reproduction  of  Creigh  ton's  translation  of  the  account  of 
the  subject  in  Hirsch's  Handbook  of  Geographical  and  Historical  Pathol- 
ogy, the  author  regarding  any  attempt  to  improve  upon  the  work  of  Hirsch 
as  useless. 

Part  II.  treats  of  Malarial  Diseases. 

Under  the  heading  Malarial  Intermittent  Fevers,  ague  and  its  varieties 
are  considered.  The  latter  comprises  masked  intermittents,  pernicious 
intermittent,  algid  pernicious  intermittent,  and  comatose  pernicious  inter- 
mittent (congestive  fever). 

Under  the  heading  Continued  Malarial  Fevers  are  considered  simple  re- 
mittent fever,  ardent  malarial  fever,  adynamic  remittent  fever,  pernicious 
remittent  fever,  and  complicated  remittent  fever.  The  latter  variety  com- 
prises those  cases  of  all  the  other  types  which  are  modified  in  important 
particulars  by  cerebral,  enteric,  or  gastric  complications. 

The  final  chapter  is  devoted  to  the  subject  of  hemorrhagic  malarial 
fever,  which  might  properly  be  included  under  the  heading  complicated 
malarial  fever.  But,  inasmuch  as  the  nature  of  the  complication  is  not  defi- 
nitely known,  and  as  the  term  hemorrhagic  simply  expresses  a  clinical  fact, 
but  does  not  commit  us  to  any  theory  as  to  the  course  of  the  hematuria, 
there  can  be  no  objection  to  the  designation,  which  does  not  apply  with 


186 


Reviews. 


[Jan. 


equal  force  to  the  other  clinical  varieties  of  malarial  fever,  that  have 
been  separately  described,  e.  g.,  pernicious  intermittent  and  remittent 
fever,  ardent  malarial  fever,  etc. 

The  second  part  of  the  work  is  ably  written,  sufficiently  full  and  ex- 
plicit for  the  reference  of  the  practitioner,  and  up  to  date.  It  is  largely 
and  confessedly  a  compilation,  and  therefore  lacks  much  of  the  impress  of 
the  author's  individuality,  which  constitutes  the  charm  of  the  first  part.  In 
pointing  out  this  fact  we  are  not  unmindful  that  judicious  compilation  is 
an  art  that  is  alike  necessary  and  productive  of  the  most  useful  results. 

Dr.  Sternberg's  work  is  an  exceedingly  well-timed,  satisfactory,  and 
useful  book.  J.  C.  W. 


Art.  XVIII — -Clinical  and  Pathological  Observations  on  Tumors  of 
the  Ovary,  Fallopian  Tube,  and  Broad  Ligament.  By  Alban  H.  G. 
Doran,  F.R.C.S.,  Assistant  Surgeon  to  the  Samaritan  Free  Hospital, 
formerly  Anatomical  and  Pathological  Assistant  to  the  Museum  of  the 
Roval  College  of  Surgeons  of  England.  With  thirty-two  illustrations. 
8vo.,  pp.  189.    London,  1884. 

Any  book  from  the  pen  of  a  member  of  the  staff  of  the  Samaritan 
Free  Hospital  is  sure  to  present  something  of  interest  and  worthy  of  con- 
sideration. Anticipation  is  not  lessened  when  the  title-page  bears  the 
name  of  a  gentleman  well  known  from  frequent  contributions  to  journals 
and  numerous  valuable  papers  in  the  transactions  of  societies,  on  the 
pathology  of  ovarian  and  pelvic  tumors.  This,  his  first  contribution  to 
standard  literature,  is  of  the  scientific  and  practical  character  to  be 
expected  from  the  position  he  occupies  and  the  rich  field  of  observation 
at  his  command.  The  material  upon  which  it  is  based  is  derived  from 
six  hundred  and  five  abdominal  sections,  at  which  he  has  been  present  as 
operator  or  assistant,  from  November,  1877,  to  March,  1884.  Of  these, 
three  hundred  and  sixty-six  were  operations  for  the  removal  of  multi- 
locular  ovarian  tumors. 

The  two  aspects  of  the  book  are  by  no  means  so  well  balanced  in  the 
body  as  on  the  title-page,  the  pathological  far  preponderating  over  the 
clinical.  For  obvious  reasons  this  is  to  be  regretted,  without  disparaging 
the  one  or  unduly  estimating  the  other.  The  book  would  certainly  be 
more  generally  useful  and  interesting  had  it  been  more  closely  directed  to 
the  practical  aspects  of  the  subject.  As  presented  it  is  not  a  systematic 
treatise,  either  pathological  or  clinical,  but  an  assemblage  of  chapters  on 
various  subjects  not  necessarily  connected  with  each  other,  in  which  cases 
are  referred  to  and  some  points  of  them  noted,  without  being  detailed, 
and  in  which  a  few  practical  points  are  so  well  presented  that  the  reader 
cannot  but  wish  that  they  had  been  all  given.  It  is  a  book,  then,  for  the 
practitioner  rather  than  the  student  ;  indeed,  it  is  not  at  all  adapted  for 
the  latter,  but  will  be  perused  with  interest  and  profit  in  direct  ratio  to 
the  amount  of  practical  knowledge  of  the  subject  the  reader  already  pos- 
sesses. It  may  seem  unfair  not  to  allow  an  author  his  own  choice  as  to 
manner  of  presentation,  but  it  seems  clear  that  precisely  because  the  work 
has  been  prepared  for  practitioners  will  it  occasion  great  disappointment 
to  find  the  most  important  practical  points  of  the  subject,  some  of  them 


1885.] 


Dor  an,  Tumors  of  the  Ovary. 


187 


yet  undecided  questions,  carefully  avoided.  The  preface  states  that 
"  statistics  of  mortality,  the  merits  of  the  antiseptic  system,  the  use  of 
the  drainage  tube,  the  weight  of  tumors,  and  the  nature  of  their  fluid  con- 
tents" are  not  to  be  touched  upon. 

The  first  two  chapters  are  upon  multilocular  and  glandular  cysts.  In 
the  very  first  paragraph  the  author  plunges  into  the  minute  pathology  of 
the  origin  of  ovarian  tumors  by  a  denial  of  the  existence  of  Pfliiger's 
tubes,  and  a  consideration  of  the  sources  of  error  in  regard  to  them. 
Without  attempting  to  follow  him  through  those  portions  of  the  work 
where  illustrations  are  necessary  to  a  clear  understanding  of  the  text,  his 
opinion  as  to  the  origin  of  multilocular  tumors  is  that  it  takes  place  in 
some  arrest  of  the  downward  progress  of  the  normal  degeneration  of  the 
atrophying  follicles,  rather  than  in  the  dilatation  of  mature  follicles: — 

"I  cannot  help  thinking  that  the  origin  of  cystic  disease  is  to  be  sought  from 
careful  and  prolonged  study  of  the  different  changes  which  follicles  in  process  of 
atrophy  may  undergo,  when  influences  which  it  may  be  impossible  to  trace  pre- 
vent the  atrophy  from  ever  being  completed."  .  .  .  "The  most  recent 
labors  of  embryologists  and  pathologists  all  point  to  a  follicular  origin  for  cystic 
disease  of  the  ovary." 

That  portion  of  the*  second  chapter  relating  to  fused  ovarian  cysts  is  of 
great  interest  and  practical  value.  The  tendency  of  ovarian  cysts  to  open 
into  each  other  when  in  contact  is  well  known,  and  the  fact,  therefore, 
that  multilocular  cysts  from  each  ovary  sometimes  become  fused  together 
is  not  surprising.  The  condition  of  things  brought  about  by  this  process 
may  be  such  as  to  puzzle  the  most  experienced  operator,  and  when  pelvic 
adhesions  also  exist  very  much  increases  the  difficulties  of  the  operation, 
and  consequently  adds  to  the  danger  for  the  patient.  The  author  gives 
the  leading  particulars  of  five  cases  of  this  kind  which  he  has  seen,  one 
of  which  was  fatal: — 

"In  the  five  cases  the  second  pedicle,  that  is,  that  which  was  recognized  as  a 
pedicle  after  another  had  already  been  detected,  was  usually  taken  at  first  for  an 
adhesion,  and  one  of  the  two  pedicles  was  always  much  smaller  than  the  other." 

"  All  were  very  troublesome  to  the  operator.  In  all,  the  pedicles  were  secured 
by  transfixion,  the  process  being  invariably  difficult.  As  a  rule,  adhesions 
existed,  and  the  uncertainty  produced  in  the  minds  of  the  operator  and  his  assist- 
ants, when  an  anomaly  of  this  kind  is  first  inspected,  is  an  element  which  adds 
to  the  tediousness  of  cases  of  this  description." 

In  regard  to  the  technique  of  diagnosis  the  author  assumes  that  the 
reader  is  acquainted  with  the  writings  of  experienced  operators,  and  he 
only  just  touches  upon  some  of  the  minor  points,  which  are  not  unimpor- 
tant, as  is  nothing  relating  to  the  diagnosis  of  abdominal  tumors,  but 
which  may  be  readily  overlooked  or  neglected  by  the  inexperienced.  As 
to  one  of  these  we  must  take  issue  with  him  ;  the  pockets  do  not,  in  our 
opinion,  give  proper  warmth  to  the  hands,  nor  are  they  better  than  immer- 
sion in  warm  water.  It  seems  strange  that  the  softening  effect  of  water  in 
improving  the  touch  should  escape  notice  where  special  attention  is  being 
paid  to  lesser  details. 

•A  possibility  of  diagnosis  from  chemical  examination  of  the  fluid  con- 
tents of  ovarian  cysts  is  denied  by  the  author,  as  by  other  late  authorities. 
We  demur,  however,  to  the  statement  that  "  chemical  tests  are  of  a  kind 
unsuitable  for  the  surgeon,"  and  suggest  that  it  is  not  necessary  for  him 
to  "  carry  spectroscopes  arid  other  apparatus  about  with  him,"  in  order  to 
avail  himself  of  their  aid  in  diagnosticating  abdominal  tumors.  We 


188 


Reviews. 


[Jan. 


looked  here  with  deep  interest  for  some  facts,  or  at  least  some  expression 
of  opinion,  in  regard  to  the  presence  or  absence  of  the  ovarian  cell,  first 
described  and  held  by  Dr.  Drysdale  as  important  in  a  diagnostic  view. 
The  subject  is  not  mentioned,  and  this  cannot  but  be  considered  a  serious 
omission  in  a  work  containing  so  much  relating  to  the  microscopic  appear- 
ances of  the  solids,  and  where  there  seems  to  be  a  right  to  expect  some 
notice  of  it. 

The  different  appearances  presented  to  the  eye,  upon  opening  the  abdo- 
men, by  dermoid  and  parovarian  cysts,  multilocular  ovarian  and  uterine 
tumors,  are  stated  and  commented  on,  as  well  as  the  changes  in  ap- 
pearance which  are  produced  by  inflammation  and  twisting  of  the  pedi- 
cle. A  careful  study  of  these  seems  to  the  author  to  justify  the  statement 
that  "  the  smoother  and  shinier  and  the  more  silvery  the  cyst  wall  appears 
wrhen  exposed  by  abdominal  incision,  the  better  the  case  will  be  for  the 
patient  and  for  the  operator." 

The  third  chapter  of  the  book  is  devoted  to  the  consideration  of  the 
parovarium  and  its  relation  to  cystic  disease  of  the  broad  ligament  and  to 
simple  broad  ligament  cysts.  It  is  an  excellent  chapter,  and  it  would  be 
difficult  to  refer  a  student  to  any  work  where  he  could  get  a  better  under- 
standing of  the  subject.  By  means  of  a  diagram*  the  relations  of  the 
different  organs  are  shown,  and  the  different  points  of  origin  of  cysts 
indicated.  A  very  large  proportion  of  the  cystic  tumors  of  this  region 
are  not  of  parovarian  origin.  The  author  believes  that  this  structure  has 
been  as  misleading  in  the  pathology  of  the  ligament  as  Pfliiger's  tubes  in 
regard  to  the  ovary,  and,  although  it  is  not  distinctly  stated,  it  is  to  be 
inferred  that  the  origin  of  cysts  is  independent  of  the  parovarium  in  the 
majority  of  cases.  He,  therefore,  prefers  the  term  "  simple  cyst  of  the 
broad  ligament,"  rather  than  "parovarian  cysts,"  when  speaking  of  cysts 
of  this  region  independent  of  the  ovary  : — 

"  It  is  often  from  a  minute  cyst  of  this  kind,  free  from  the  parovarian  tubes, 
that  is  developed  the  large  cyst  commonly  termed  parovarian,  with  its  thin  trans- 
parent wall,  its  single  cavity,  lined  with  flat  or  low  columnar  epithelium,  and  its 
clear  watery  contents.  I  have  examined  over  one  hundred  broad  ligament  cysts 
of  this  kind,  perfectly  free  from  the  parovarium  and  from  the  tube,  and  ranging 
from  one-fortieth  of  an  inch  to  one  inch  in  diameter." 

A  characteristic  of  cysts  arising  from  the  parovarium  is  to  develop  papil- 
lomatous growths  on  their  interior.  Upon  bursting  of  the  cyst  wall  these 
papillary  growths  spread  over  the  broad  ligament  and  neighboring  organs 
with  great  rapidity,  and  to  this  form  of  tumor  the  next  chapter  is  entirely 
devoted.  The  possible  presence  of  these  papillomatous  growths  in  the  in- 
terior of  any  simple  pelvic  cysts  is  given  as  an  argument  against  tapping. 
In  deciding  against  this  measure,  the  author  acknowledges  that  he  has  the 
high  authority  of  Mr.  Keith  against  him,  as  he  will  continue  to  have  the 
practice  of  every  practitioner  who  has  ever  had  a  permanent  cure  of  such 
a  cyst  from  a  single  tapping.  However  low  may  be  the  mortality  of  the 
operation  for  extirpation,  all  but  those  who  operate  very  frequently  will 
prefer  the  lesser  dangers  of  tapping.  That  the  operation  for  simple  cyst 
of  the  broad  ligament  is  very  easy  and  simple,  and  the  mortality  exceed- 
ingly low,  is  well  known.  To  merely  say,  however,  that  "  this  subject 
has  been  discussed  by  Mr.  Tait,"  is  hardly  just  to  that  gentleman. 

Although  the  removal  of  these  cysts  is  generally  easy,  the  author  recog- 
nizes the  clinical  fact  that  sometimes,  when  they  burrow  downwards,  they 
are  without  any  proper  pedicle,  and  their  removal  is  exceedingly  difficult. 


1885.] 


Dor  an,  Tumors  of  the  Ovary. 


189 


It  is  here  that  the  process  of  enucleation  may  come  into  play,  and  the  term 
is  certainly  preferable  to  that  of  "  shelling  out,"  which  is  repeatedly  used 
by  the  author.  He  does  not  deem  it  worth  while  to  mention  the  name  of 
Dr.  Miner,  of  this  country,  in  connection  with  this  procedure.  We  say  so, 
because  it  would  scarcely  be  fair  to  presume  that  he  could  be  ignorant  of 
the  origin  of  so  important  a  modification  of  the  operation  of  ovariotomy. 
We  hoped  to  find  here  some  notice  of  a  procedure  suggested  by  our 
limited  experience,  and  which  we  regret  not  having  put  in  force  in  one  of 
these  cases  of  sessile  cystic  growths;  that  is,  to  cut  out  a  portion  of  the 
walls,  and  stitch  the  edges  of  the  opening  to  the  abdominal  walls.  By 
this,  the  dangers  of  separation  of  close  adhesions  deep  in  the  pelvis  could 
be  avoided,  and  by  drainage  doubtless  a  permanent  cure  effected. 

One  chapter  of  the  work  is  on  Dermoid  Cysts  of  the  Ovary,  a  departure 
from  the  normal,  which,  to  the  author,  "appears  to  be  closely  and  insepa- 
rably linked  with  some  of  the  most  profound  mysteries  of  organic  life." 
It  contains  the  pathological  particulars,  and  the  peculiarities  observed 
during  operation  of  thirty-one  observed  cases.  The  relation  of  this  form 
of  tumor  to  malignant  disease  is  discussed,  and  the  statement  made  that 
Mr.  Thornton's  experience  has  given  several  cases  where  malignant  de- 
posits have  recurred  in  the  pelvis  two  or  three  years  after  the  removal  of 
large  dermoid  cysts  containing  soft  white  growths  that  strongly  resemble 
sarcomata.  Acknowledging  the  difficulty  of  a  decision  as  to  many  forms 
of  outgrowth  from  dermoid  cysts,  the  author  says  : — 

"  With  regard,  however,  to  the  sarcomata,  these  growths  are  considered  to  be 
made  up  of  more  or  less  embryonic  connective  tissue.  In  dermoid  cysts,  connec- 
tive tissue  exists  in  all  its  stages  of  development,  and  the  last  two  examples  which 
1  have  described  show  that  the  perfect  tissue  may  be  seen  passing  into  less  well- 
developed  structures,  bearing  every  resemblance  to  the  new  growths  known  as 
spindle-celled  sarcoma  and  round-celled  sarcoma  elsewhere.  What  is  far  more 
serious  is  the  fact  that  experienced  clinical  authorities  declare  that  dermoid  cysts, 
with  ill-developed  tissue  of  this  kind,  give  rise  to  all  the  worst  results  which 
follow  the  development  of  sarcomata  elsewhere,  so  that  it  is,  pathologically  speak- 
ing, not  illogical  to  speak  of  sarcoma  of  a  dermoid  cyst  as  a  tumor  of  a  tumor." 

In  the  chapter  on  Solid  Tumors  of  the  Ovary,  the  author  teaches  that 
it  often  becomes  the  surgeon's  duty  to  make  an  exploratory  incision.  He 
has  seen  fourteen  cases  in  which  nothing  was  removed  ;  none  of  them  proved 
fatal,  and  he  places  the  risk  of  this  procedure  very  low.  If  the  tumor 
proves  to  be  ovarian,  it  may  be  removed,  and  even  if  sarcomatous  in 
character,  "it  certainly  does  not  tend  to  recur  as  rapidly  as  a  sarcoma  in 
other  parts  of  the  body."  It  is  matter  for  regret  that  diagnosis,  in  con- 
nection with  solid  pelvic  tumors,  is  not  considered  in  detail,  or  at  a  length 
at  all  commensurate  with  its  difficulties. 

Two  chapters  are  devoted  to  the  Operation  of  Ovariotomy,  but  the 
subject  is  considered  in  a  fragmentary  character ;  the  first  is  on  the  ad- 
dominal  wound,  which  he  thinks  should  be  free,  and  on  adhesions ;  the 
second  is  devoted  to  the  complete  intra-peritoneal  ligature  of  the  pedicle, 
and  is  interesting,  but  the  arguments  have  been  closed,  and  the  question 
is  settled.  One  important  point  must  not  be  overlooked  ;  he  fully  recog- 
nizes it,  but  does  not  emphasize  it  as  it  deserves  to  be.  In  the  following 
paragraph  we  furnish  the  italics  : — 

"The  shock  during,  and  immediately  after  the  separation  of  extended  adhe- 
sions is  often  very  marked,  especially  if  the  patient  be  not  thoroughly  under  the 
influence  of  the  anodsthetic.,'> 


190 


Reviews. 


[Jan. 


There  can  be  no  question  of  the  truth  of  this  proposition,  and  the  ope- 
rator on  abdominal  tumors  should  instruct  his  administrator  of  anaesthetics 
to  deepen  these  effects  when  adhesions  are  numerous  and  firm. 

The  chapter  on  Morbid  Conditions  of  the  Kidney,  associated  with 
ovarian  tumors,  is  one  of  the  best,  if  not  the  best  of  the  book.  The  im- 
portance of  the  subject  cannot  be  over-estimated,  and  the  lethal  influence 
of  these  organs  is  so  strikingly  shown,  that  hereafter  no  "  general  surgeon" 
will  continue  to  believe  "that  nothing  can  destroy  life  after  ovariotomy 
but  septicaemia  or  peritonitis"  ! 

"  I  wish  to  record  the  fact  that  in  thirty-two  out  of  over  forty  necropsies  that 
I  have  made  on  the  bodies  of  patients  -who  have  died,  either  after  ovariotomy,  or 
with  large  ovarian  tumors  in  the  abdomen,  I  found  that  the  kidneys  presented 
very  distinct  morbid  appearances." 

The  different  kinds  of  urine  are  given,  and  their  probable  influence  on 
the  operation,  the  effect  of  pressure  on  the  ureters  traced  backwards  to  the 
kidneys,  and  the  changes  there  produced  are  described.  The  author 
fortifies  himself  by  quotation  of  the  views  of  Mr.  Marcus  Beck,  as  given 
in  Reynolds' 's  System  of  Medicine.  An  abstract  of  the  morbid  appearances 
presented  by  the  kidneys  in  each  of  the  thirty-two  cases  is  also  given. 

There  are  several  other  chapters  which  we  cannot  examine  in  detail. 
All  are  interesting  and  instructive,  because  based  upon  clinical  observa- 
tions. The  book  cannot  be  considered  other  than  as  a  most  valuable 
contribution  to  the  subject.  We  must  express  regret,  however,  that 
the  work  of  our  countrymen  receives  so  little  notice,  even  in  regard  to 
points,  as  has  been  mentioned,  where  they  deserved  it;  but  three  names 
belonging  to  this  country  appear  in  its  pages  :  Nathan  Smith,  Dr.  Noeg- 
gerath,  and  Dr.  Skene.  We  regret,  too,  the  fragmentary  manner  of 
presentation  of  the  subjects  considered,  already  alluded  to,  and  trust  that 
one  who  shows  himself  so  able,  and  who  is  so  well  supplied  with  clinical 
material,  will  before  long  furnish  a  more  systematic  and  methodical  treatise. 
Whatever  shortcomings  may  be  found  in  this  production,  there  is  no 
question  as  to  the  spirit  which  pervades  it ;  this  is  thoroughly  and  purely 
scientific,  as  may  be  seen  from  the  following  : — ■ 

"I  have  searched  for  cases  like  these  for  several  years,  but  these  two  examples 
seem  to  be  a  protest  against  dogmatic  pathology.  The  blank  formula  '  such  and 
such  a  disease  never  does  so  and  so,'  must  not  be  filled  up  and  applied  rashly  by 
the  pathologist.    Yet  it  should  not  be  forgotten  that  the  reverse  principle,  this 

specimen  is  described  in  order  to  disprove  's  assertion  'that  such  and  such 

a  disease  never  does  so  and  so' — is  an  equally  fruitful  source  of  error.  To  avoid 
both  these  sources  of  error,  I  have  described  the  above  cases  at  length — perhaps, 
at  tedious  length — but  they  represent  what  I  have  seen,  and  I  leave  others  to 
draw  inferences  from  them."  J.  C.  R. 


Art.  XIX  The  Principles  of   Ventilation  and  Heating,  and  their 

Practical  Application.  By  John  S.  Billings,  M.D.,  LL.D. 
(Edinb.),  Surgeon  U.  S.  Army.  8vo.,  pp.  216.  Seventy-two  illustra- 
tions.   New  York  :  The  Sanitary  Engineer,  1884. 

The  law  of  demand  and  supply  is  well  illustrated  by  this  book,  and  the 
circumstances  of  which  it  is  the  outcome.    Tracing  back  their  train,  one 


1885.]    Billings,  The  Principles  of  Ventilation  and  Heating.  191 


arrives  at  the  need  of  a  practical  guide  in  the  application  of  the  princi- 
ples of  ventilation  and  heating,  which  shall  give  directions  from  a  point  of 
view  which  may  be  called  subjective.  The  object  sought  is  the  health 
and  comfort  of  the  human  body,  and  the  subjective  knowledge  of  what 
practically  affects  it  for  good  or  ill  may  be  conceived  to  be  best  attained 
by  a  mind  well  trained  in  medical  science,  to  which  has  been  added  a 
large  experience  in  the  practical  study  of  questions  relating  to  the  con- 
struction of  human  habitations. 

Many  a  high-sounding  scheme  for  "  the  best  ventilated  building"  has 
come  to  disappointment,  and  wTaste  of  money  and  life,  by  the  undue  pre- 
dominance of  professional  ideas  on  one  side  or  the  other.  The  best 
results  may  come  from  medical  knowledge,  which  keeps  in  view  the  im- 
portance of  the  principles  treated  in  this  book,  with  a  due  comprehension 
of  the  conditions  that  beset  the  architect,  when  there  is  also  the  happy 
faculty  of  imparting  knowledge  in  a  practical  way.  Such  a  combination 
is  rare  enough  to  make  it  of  great  value  as  a  source  of  information,  which 
is  especially  liable  to  be  asked  for  by  those  who  have  not  the  time  or 
interest  in  the  subject  to  study  it  for  themselves.  Indeed  the  idea  has 
been  too  common  in  regard  to  ventilation,  that  it  is  a  subject  requiring 
little  study  ;  that  its  whole  secret  is  to  be  found  out  by  some  magic  rule 
of  thumb.  Many  persons  think  they  know  all  about  it,  so  there  is  no 
end  of  quackery  in  this  matter.  The  holes  they  make  in  the  walls  and 
floors  of  their  rooms,  and  the  pipes  and  flues  which  honeycomb  their 
houses,  usually  work  the  wrong  way.  The  writer  of  this  article  is  often 
reminded  of  his  college  professor,  who  taught  physics,  and  who,  wise  by 
experience,  was  never  caught  by  an  unsuccessful  experiment.  For  ex- 
ample, he  might  say,  while  suiting  the  words  to  the  action  :  "  Now,  if  I 
let  fall  this  ball  here,  the  other  one  should  rise  there — but  it  doesn't !"  A 
good  reason  could  always  be  given  for  a  failure,  however. 

Many  who  would  wish  to  be  better  informed  shrink  from  the  study  of 
the  laws  of  heat  and  pneumatics  necessary  to  demonstrate  to  their  own 
understanding,  the  rationale  of  the  principles  that  are  the  key  to  the 
whole  subject.  Probably  many  readers  of  this  book,  lucid  as  it  is,  and 
shorn  of  much  technicality,  will  sympathize  with  the  young  architect  who 
was  its  "immediate  cause"  by  his  request  of  the  author  for  "some  plain, 
practical  directions  as  to  the  best  methods  of  arranging  the  ventilation  of 
a  building,  to  be  given,  as  far  as  possible,  in  the  form  of  specifications 
which  can  be  readily  understood  by  an  intelligent  builder,  and  not  in  the 
form  of  abstruse  mathematical  formula?."  He  complained  that  the  books 
he  had  examined  contained  only  "  long-winded  scientific  speculations 
about  the  physics  of  gases,"  etc.,  and  that  he  "could not  obtain  from  them 
a  simple  statement  as  to  how  to  ventilate  a  large  school-house,"  the 
problem  that  then  interested  him.-  Naturally  the  author  finds  a  ready 
counterpart  of  his  inquirer,  in  the  kind  of  aspirant  for  medical  education 
wTho  "does  not  wish  to  take  the  trouble  to  learn  anatomy  and  physiol- 
ogy," but  wants  ready-made  information  for  common  use,  conveniently 
packed  "  in  a  vest-pocket  manual,  which  can  be  consulted  as  occasion 
demands." 

A  series  of  papers  contributed  to  The  Sanitary  Engineer,  entitled 
"  Letters  to  a  Young  Architect  on  Ventilation  and  Heating,"  originally 
prepared  to  answer  questions  sent  to  that  journal,  forms  the  basis  of  this 
work,  which  contains  the  substance  of  those  papers,  the  whole  being  re- 
arranged and  in  part  re-written,  and  new  matter  and  illustrations  being 


192 


Reviews. 


[Jan. 


added.  It  is  not  intended  to  be  a  systematic  manual  on  ventilation  and 
heating,  but  rather  to  present  the  general  principles  which  should  guide 
one  in  judging  of  the  merits  of  various  systems  of,  and  appliances  for, 
ventilation,  and,  as  far  as  possible,  without  the  use  of  technical  expres- 
sions or  of  any  but  the  simplest  mathematical  formulas.  It  is  desired  to 
present  the  subject  in  such  a  way  that  architects  will  appreciate  its  im- 
portance in  their  work,  and  understand  its  difficulties  and  the  general 
principles  which  should  guide  them  in  endeavoring  to  overcome  these 
difficulties. 

The  author  hopes  that  the  volume  may  serve  to  meet  the  wants  of 
architects,  physicians,  and  others  whose  queries  appear  from  time  to  time 
on  this  subject.  His  own  experience  undoubtedly  gives  him  ample 
warrant  for  the  belief  that  there  is  a  demand  for  an  explanatory  work  of 
this  kind.  Those  who  read  the  book,  and  appreciate  the  author's  grasp 
of  the  subject,  will  thank  the  "young  architect"  for  his  frank  avowal  of 
his  difficulty,  which  found  the  response  ready  to  the  demand  ;  and  they 
will  find  in  the  work  a  mine  of  information,  stated  with  the  directness 
and  force  which  go  straight  to  the  point  and  waste  no  time,  clearly  and 
intelligibly,  and  with  a  wealth  of  quotation  from  many  authorities  of  valu- 
able condensed  statements  of  what  they  have  contributed  to  the  subject. 
The  peculiar  excellence  of  the  work  is  in  its  elucidation  of  essential  and 
elementary  principles,  and  the  plainness  with  which  their  application  is 
explained,  aided  by  ample  illustration.  One  can  hardly  fail  to  master  a 
few  simple  laws  that  govern  the  production  and  communication  of  heat, 
and  the  movement  of  air,  which  will  give  a  practical  insight  into  the  sub- 
ject, sufficient  to  make  it  easy  to  understand  the  thousand-and-one  appa- 
rently confusing  variations  of  the  problem  of  ventilation  of  houses  and 
rooms,  and  to  reduce  the  difficulties  to  simple  terms  of  the  application  of 
common  principles.  Such  knowledge  as  this  is  invaluable  to  every  phy- 
sician, if  for  nothing  more  than  to  enable  him  to  extemporize  simple 
methods  for  the  ventilation  of  sick  rooms. 

The  first  three  chapters  deal  with  these  laws,  and  the  amount  of  air 
supply  required.  As  a  first  axiom  to  be  kept  in  mind,  it  is  declared,  as 
applying  especially  to  the  large  cities  in  our  Northern  States,  that  "  in 
this  climate,  it  is  impossible  to  have,  at  the  same  time,  good  ventilation, 
sufficient  heating,  and  cheapness."  "  Good  ventilation"  is  defined  as  not 
exactly  "  the  removal  of  foul,  and  the  introduction  of  fresh  air,"  but  as 
including,  "  in  the  great  majority  of  cases,  the  idea  of  a  thorough  mixing 
of  pure  with  impure  air,  in  order  that  the  latter  may  be  diluted  to  a  cer- 
tain standard." 

The  true  relations  of  carbonic  acid  to  questions  of  ventilation  are 
treated  in  an  interesting  way.  Its  importance  is  not  because  it  is  inju- 
rious of  itself,  even  in  the  proportions  found  in  our  worst  ventilated  rooms, 
but  because  it  "  is  usually  found  in  very  bad  company,  and  that  variations 
in  its  amount  to  the  extent  of  three  or  four  parts  in  ten  thousand  indicate 
corresponding  variations  in  the  amount  of  those  gases,  vapors,  and  sus- 
pended particles  which  are  really  offensive  and  dangerous  ;  and  also  be- 
cause we  have  tests  by  which  we  can,  with  comparative  ease  and  cer- 
tainty, determine  the  variations  in  the  carbonic  acid."  The  normal 
amount  of  carbonic  acid  in  fresh  air  being  4  parts  in  10,000,  the  added 
**  carbonic  impurity  should  never  exceed  2  or  at  the  most  3  parts  in 
10,000  of  the  air  in  a  room."  Convenient  methods  of  testing  the  air  are 
described. 


1885.].    Billings,  The  Principles  of  Ventilation  and  Heating.  193 


The  production  and  communication  of  heat,  the  movements  of  heated 
air  in  open  spaces  and  in  flues,  and  the  effect  of  different  shapes  and  sizes 
of  flues,  are  discussed  in  a  brief  and  well-written  chapter.  Theoretical 
formulae  are  given  and  explained,  but  inasmuch  as  the  results  obtained  by 
some  of  them  have  to  be  modified  by  percentages  of  allowance  for  varying 
conditions,  the  author  does  not  hesitate  to  simplify  the  formulae,  and  to 
discard  minute  calculations  ;  and  gives  some  easily  understood  practical 
rules.  The  same  may  be  said  of  the  chapter  on  the  amount  of  air  supply 
and  cubic  space,  of  which  the  author  says  that  "  it  is  just  at  this  point 
that  the  young  architect  or  engineer  is  most  likely  to  become  demoralized 
and  discouraged,"  because  of  the  great  diversity  of  opinion  among  autho- 
rities as  the  proper  methods  of  calculating  the  amount.  Several  methods 
are  given  and  their  fallacies  explained  ;  and  it  is  said  that  the  estimates 
of  sanitarians  as  to  the  amount  of  air  required  are  now  based  upon  the 
observations  of  De  Chaumont,  Parkes,  and  others. 

Assuming  that  the  air  of  an  inhabited  room  should  not  be  so  impure  as 
to  possess  the  faint  musty  odor  that  may  usually  be  perceived,  when,  as  a 
product  of  respiration,  the  proportion  of  carbonic  acid  is  increased  from 
the  normal  ratio  of  between  3  and  4  parts  in  10,000  to  between  6  and  7 
parts  in  10,000,  Parkes  shows  the  amounts  of  air  necessary  to  dilute  to 
this  standard  to  be  3000  cubic  feet  per  head  per  hour  after  the  first, 
when  the  cubic  feet  of  space  occupied  per  head  is  from  100  to  1000. 
The  author,  however,  assuming  that  all  the  fresh  air  is  to  enter  through 
the  ducts  provided  for  that  purpose,  would  advise  that  heating  surface, 
foul  and  fresh  air  flues,  and  registers  be  provided  for  an  air  supply  of  one 
cubic  foot  per  second  per  head  for  rooms  which  are  to  be  constantly  occu- 
pied. This  would  give  an  allowance  of  3600  cubic  feet  per  head,  which 
he  would  reduce  to  2500  cubic  feet  per  hour,  or  three-quarters  of  a  foot 
per  second  for  school  rooms,  halls  of  assembly,  etc.,  occupied  but  a  few 
hours  at  a  time. 

The  various  methods  of  heating  are  considered  in  Chapter  IV.  The 
author  has  come  to  the  conclusion  that  the  statements  of  the  great 
majority  of  writers,  that  direct  radiant  heat  in  a  room  is  preferable  from  a 
hygienic  point  of  view,  is  not  sustained  by  evidence  that  is  entirely  con- 
vincing. He  would,  however,  strongly  advise  that  a  fireplace  be  pro- 
vided in  every  room  which  is  to  be  inhabited  in  a  dwelling-house,  but 
rather  for  purposes  of  ventilation  than  heating,  and  as  a  cheerful  addition 
to  other  means  of  heating.  It  should  be  supplemented,  in  our  northern 
climate,  by  indirect  radiation  from  a  furnace,  or  steam  or  hot  water  appa- 
ratus, the  former,  next  to  stoves,  being  the  cheapest.  Some  very  instruc- 
tive remarks  are  also  made  in  Chapter  VI.,  on  the  use  of  fireplaces  and 
stoves,  with  illustrations  of  simple  devices  for  making  the  latter  a  means 
of  ventilation. 

The  careful  discussion  of  the  comparative  merits  and  demerits  of  steam 
and  hot- water  apparatus  is  very  practical  and  valuable,  and  indicates  that 
the  advantages  of  the  latter  method,  even  for  cold  climates,  are  yet  but 
little  understood. 

Concise,  practical,  and  intelligible  directions  are  given  in  Chapter  V. 
for  the  placing  of  flues  and  registers,  and  for  determining  their  proper 
size  ;  and  the  question  of  regulating  the  moisture  of  air  is  interestingly 
discussed.  While  English  writers  usually  state,  that  in  order  to  secure 
health  and  comfort,  the  relative  saturation  with  moisture,  of  air  to  be 
respired,  should  be  from  65  to  75  per  cent.,,  it  is  shown  that  these  figures 
No.  CLXXVII._Jan.  1885.  13 


194 


Reviews  . 


[Jan. 


will  not  apply  to  the  United  States,  where  even  a  degree  of  saturation  of 
only  15  to  20  per  cent,  is  found  to  be  consistent  with  the  absence  of  dis- 
comfort and  ill  effects. 

In  regard  to  the  plans  of  a  suburban  residence,  much  exposed  to  cold 
winds  in  winter,  given  on  pages  60-67,  illustrating  the  question  of  a  cen- 
tralized location  of  the  radiators  and  hot-air  registers  or  their  peripheral 
arrangement  in  the  outer  walls,  the  latter  being  preferred  by  the  author, 
it  may  be  interesting  to  note  that  this  plan  was  adopted  in  the  building  in 
question  with  satisfactory  results.  For  a  warmer  climate,  the  author 
thinks  the  former  plan  would  be  preferable.  The  very  different  problem 
presented  by  a  city  dwelling  is  fully  illustrated. 

The  author  pays  his  respects  to  various  patent  systems  of  ventilation 
and  heating  in  Chapter  VI.,  and  in  the  next  chapter  takes  up  fhe  subject 
of  ventilators,  cowls,  etc.,  of  which  the  variety  is  endless.  The  results  are 
quoted  of  many  experiments,  with  various  devices  for  the  purpose  of  giv- 
ing direction  to  currents  passing  through  flues  or  shafts,  or  for  enabling 
the  wind  to  produce,  accelerate,  or  prevent  such  currents  ;  fallacies  and 
errors  are  pointed  out,  and  the  philosophy  of  the  principles  involved  is 
stated  with  characteristic  clearness.  The  construction  and  location  of 
foul  air  flues  and  shafts  are  considered  at  length,  and  the  doubtful  useful- 
ness of  some  much-vaunted  forms  of  fresh  air  inlets  in  the  walls  of  rooms 
is  explained.    This  chapter  is  a  valuable  one. 

Passing  now  to  the  application  of  principles,  and  to  the  illustration  of 
the  methods  which  have  been  actually  employed,  and  by  which  the  greatest 
success  in  obtaining  fresh  air  appears  to  have  been  attained,  the  next  four 
chapters  are  devoted  to  the  subject  of  heating  and  ventilating  assembly 
rooms,  churches,  legislative  halls,  theatres,  schools,  and  hospitals.  The 
general  principles  governing  the  ventilating  arrangements  are  compara- 
tively simple,  and  the  basis  of  all  plans  and  calculations  is  the  amount  of 
fresh  air  to  be  supplied.  The  author  adopts  as  the  only  safe  rule,  that 
laid  down  by  Drs.  Parkes  and  De  Chaumont,  viz.,  that  when  the  air  in 
a  room  has  a  perceptibly  musty,  unpleasant  odor,  to  a  person  entering  it 
from  outside,  that  air  is  unfit  for  respiration,  and  will  probably,  sooner  or 
later,  produce  disease.  For  audience  halls,  occupied  not  more  than  two 
or  three  hours  at  a  time,  the  supply  should  in  no  case  be  less  than  30  cubic 
feet  of  air  per  minute,  through  the  regular  flues  of  supply  ;  and  in  legisla- 
tive buildings,  it  should  be  possible  to  furnish  at  least  45  cubic  feet  per 
person,  with  the  possibility  of  increasing  it  to  60  feet  when  desired. 

Sectional  and  If oor  plans  are  given  of  the  Houses  of  Parliament  and 
the  halls  of  the  House  of  Representatives  ;  also  of  a  number  of  noted  thea- 
tres, and  opera  houses  ;  and  not  only  are  careful  deductions  made  as  to 
what  is  desirable  in  the  matter  in  question,  but  practical  and  valuable 
instructions  are  given  on  important  points  in  making  specifications  and 
dealing  with  contractors. 

The  subject  of  schools  is  treated  in  the  same  practical  way,  and  with  a 
good  defence  of  correct  principles.  There  is  a  description  and  plans  of 
the  now  famous  Bridgeport  school-house.  In  this  building,  contrary  to 
the  usual  plan,  the  inlets  for  fresh  warm  air  are  in  the  inner  walls,  8  feet 
above  the  floor  where  the  outlets  open  into  wrarmed  exhaust  shafts.  The 
plan  seems  to  work  well,  though  experiments  described  show  that  about 
16  to  20  cubic  feet  of  air  per  minute  was  furnished  to  each  of  50  pupils, 
instead  of  30  cubic  feet  as  was  proposed.  The  author  does  not  disapprove 
this  plan  of  heating,  though  he  says,  on  page  57,  that  in  such  rooms,  the 


1885.]    Billings,  The  Principles  of  Ventilation  and  Heating.  195 


heat  production  of  such  a  number  of  occupants  is  a  factor  that  must  be 
taken  into  consideration,  and  there  is  some  danger,  by  this  method,  that 
there  will  be  unsatisfactory  distribution  of  the  fresh  air  when  the  external 
temperature  is  not  below  50°  F. 

The  chapter  on  hospitals  is  an  interesting  and  valuable  one,  as  was  to 
have  been  expected.  Such  buildings  have  received  more  attention  than 
others  in  regard  to  ventilation  and  heating,  and  yet  the  results  are  too 
often  unsatisfactory.  Several  plans  are  given  of  one-story  pavilions,  with 
long  and  circular  wards,  also  of  some  three-story  hospitals,  including  the 
Barnes,  New  York,  Roosevelt,  and  Johns  Hopkins  hospitals,  with  some 
very  satisfactory  results  of  a  long  series  of  careful  experiments  made  in 
the  first  named  by  Dr.  Huntington  of  the  U.  S.  Army. 

The  last  chapter  in  the  book  treats  of  forced  ventilation,  by  heated  as- 
pirating chimneys,  etc.,  and  an  interesting  account  is  given  of  the  use  of 
steam  coils  to  produce  a  ventilating  current  in  the  library  building  of 
Columbia  College,  with  plans.  The  use  of  fans  is  also  briefly  noticed. 
Formulas  and  rules  are  given  for  making  calculations  in  regard  to  these 
methods.  The  book  closes  with  some  ingenious  and  useful  plans  for 
switch-valves  for  mixing  warm  and  cold  air  in  inlet  ducts — an  essential 
device  for  changing  the  temperature  of  in-flowing  air  without  lessening  its 
quantity. 

While  the  work  is  not  intended  to  be  exhaustive  in  its  treatment  of  the 
subject,  it  so  goes  to  the  root  of  the  matter  as  to  furnish  the  information 
one  practically  needs  in  a  most  valuable  way.  The  book  is  printed  on 
good  paper,  but  is  worthy  of  a  better  setting  in  larger  type,  and  clearer 
wood-cuts. 

It  would  be  a  grave  omission  not  to  mention  the  pleasing  way  in  which 
this  dry  subject  is  made  fresh  and  interesting.  There  is  a  certain  hu- 
midity in  the  style,  so  to  speak,  due  no  doubt  to  the  humor  there  is  in  it, 
that  makes  it  less  hygroscopic  of  the  vital  juices  of  the  reader,  than  such 
works  usually  are.  The  author  is  reminded  of  many  things,  by  way  of 
analogy  and  illustration,  with  which  he  tersely  points  his  moral  or  enforces 
his  argument,  beginning  on  the  first  page  with  the  student  who  wanted 
his  medical  education  in  a  little  time,  and  in  a  compact  form  convenient 
for  the  vest  pocket,  and  ending  on  the  last  page  with  the  ignorant  and 
careless  engineer,  who  had  the  higher  qualification  of  being  somebody's 
"  nephew"  or  "  an  active  politician  ;"  not  omitting  to  mention  the  people 
who  were  nearly  frozen  to  death  by  their  own  fireplaces,  nor  the  schools, 
the  bad  ventilation  of  which  was  like  the  old  toper's  whiskey — "  there 
was  no  bad  whiskey,  although  some  samples  were  better  than  others." 
The  style  possesses  an  element  of  breeziness,  that  by  an  agreeable  kind 
of  perflation,  and  in  accordance  with  the  fitness  of  things,  serves  an  admi- 
rable purpose  in  ventilating  the  subject  of  ventilation.  E.  C. 


196 


Reviews. 


[Jan. 


Art.  XX — Diseases  of  the  Heart  and  Thoracic  Aorta.  By  Byrom 
Bramwell,  M.D.,  F.R.C.P.E.;  Lecturer  on  the  Principles  and  Prac- 
tice of  Medicine,  and  on  Practical  Medicine  and  Medical  Diagnosis  in 
the  Extra-Academical  School  of  Medicine,  Edinburgh ;  Pathologist  to 
the  Edinburgh  Royal  Infirmary,  etc.,  etc.  8vo.,  pp.  782,  with  317 
illustrations.    New  York  :  D.  Appleton  &  Co.,  1884. 

Dr.  Bramwell,  occupied  during  recent  years  in  teaching  in  the  Extra- 
Mural  School  of  Medicine  in  Edinburgh,  and  as  Pathologist  to  the  Royal 
Infirmary,  formerly  enjoyed  at  Newcastle-on-Tyne  the  advantages  of  the 
double  position  of  physician  and  pathologist  to  the  infirmary.  The  good 
results  of  a  training  which  has  enabled  him  to  acquire  large  experience 
at  first  hand  and  at  the  same  time,  both  in  pathological  anatomy  and  in 
clinical  pathology,  were  apparent  in  his  excellent  work  on  Diseases  of  the 
Spinal  Cord,  issued  two  years  ago,  and  well  received  in  his  own  and  in 
this  country  as  a  text-book. 

The  results  of  such  a  training  are  still  more  plainly  seen  in  the  present 
treatise.  It  is  the  book  of  a  teacher  for  students — not  only  for  begin- 
ners, but  also  for  students  of  older  growth  and  large  experience.  Here 
we  may  say,  that  not  being  subject  to  the  science-primer  and  quiz-com- 
pend  levity,  we  hold  that  even  beginners  in  the  study  of  medicine  will 
save  money,  energy,  and  time  by  buying  and  studying  the  best  books 
which  treat  fully  and  connectedly  of  their  subjects  ;  that  the  difficulty 
about  the  short-cuts  to  knowledge  is  that  they  are  usually  no  thoroughfare, 
and  that  those  advising  their  use  are  apt  to  prove  false  guides.  For  he 
who  would  arrive  satisfactorily  at  the  goal  must  follow  the  arduous  path 
which  has  been  laid  out  by  honest  workers  at  great  labor  and  expense. 

The  habits  of  the  class-room  are  shown  in  the  ordering  of  the  topics 
and  in  the  almost  chart-like  arrangement  of  the  various  divisions,  sub-di- 
visions, and  headings.  This  elaborately  methodical  arrangement  leads  to 
repetitions  and  is  inconvenient  in  continuous  reading,  but  it  greatly  facili- 
tates the  study  of  the  subject  and  reference  to  particular  divisions  of  it. 
We  learn  from  the  preface  that  the  subject  matter  of  the  work  was  deliv- 
ered almost  exactly  as  it  stands  in  the  form  of  lectures  to  the  author's 
class  at  the  beginning  of  the  winter  sessions  of  1883-84.  It  is,  however, 
the  result  of  a  long  period  of  preparation,  for  we  are  told  that  during  the 
past  fifteen  years  the  author  has  been  constantly  thinking  and  talking 
about  the  subject,  and  steadily  accumulating  the  clinical  knowledge  and 
pathological  material  necessary  for  the  production  of  such  a  work. 

Dr.  Bramwell  evidently  places  a  high  estimate  upon  the  value  of  illus- 
trations. Of  the  317  which  have  place  in  this  volume  many  are  full-page 
lithographs  of  naked-eye  and  microscopical  subjects.  All  these  litho- 
graphs and  more  than  half  of  the  whole  number  of  illustrations  are 
original. 

The  introductory  anatomical  and  physiological  remarks  occupy  forty-five 
pages,  and  fully  represent  the  knowledge  of  the  subject  in  its  present  state. 
At  the  outset  the  author  emphasizes  the  fact,  too  often  overlooked,  that 
the  heart  is  not  merely  a  mechanical  but  that  it  is  also  a  muscular  pump, 
and  that  its  action  presents  problems  that  are  partly  mechanical  and  partly 
vital.  He  has  drawn  largely  upon  Dr.  Gaskell's  brilliant  researches 
relating  to  the  heart-muscle  and  its  automatic  mechanism  and  the  general 
subject  of  cardiac  innervation,  and  has  not  overlooked  the  recent  contri- 


1885.]    Bramwell,  Diseases  of  the  Heart  and  Thoracic  Aorta.  197 


butions  to  the  physiology  of  the  heart  by  Martin,  Sedgwick,  Sewall,  Don- 
aldson, and  other  workers  in  the  biological  laboratory  of  the  Johns  Hopkins 
University.  At  this  point  we  observe  a  defect  in  the  book,  which  repeat- 
edly occurs  and  is  likely  to  be  a  cause  of  some  annoyance  to  the  close 
student.  It  is  the  omission  of  bibliographical  references.  In  view  of  the 
fact  that  the  "  Studies  "  from  the  biological  laboratory  of  the  Johns  Hopkins 
University  and  the  Journal  of  Physiology  are  neither  commonly  read 
nor  easy  of  access  to  a  great  number  of  the  readers  of  Dr.  Bramwell's 
book,  the  following  passage,  which,  without  reference  or  further  explana- 
tion, comprises  all  that  is  said  under  the  heading  of  "The  Arterial  Blood 
Supply  of  the  Heart,"  may  be  taken  as  a  fair  example  to  illustrate  this 
fault  of  omission  : — 

"As  we  all  know,  arterial  blood  is  conveyed  to  the  cardiac  muscle  by  the  cor- 
onary arteries,  and  until  quite  recently  it  was  supposed  by  many  of  our  leading 
physiologists  and  physicians  that  in  consequence  of  the  relative  position  of  the 
parts,  the  orifices  of  the  coronary  arteries  must  of  necessity  be  closed  during  the 
systole  of  the  ventricle,  the  valve  flaps  being  pressed  against  the  orifices  of  the 
coronary  arteries  by  the  blood  stream  in  its  passage  from  the  ventricle  into  the 
aorta. 

"The  recent  experiments,  however,  of  Martin  and  Sedgwick  seem  conclu- 
sively to  show  that  this  supposed  closure  does  not  occur,  and  that  the  coronary, 
like  all  the  other  arteries  of  the  body,  are  distended  during  the  systole  of  the 
heart. 

"  These  observers  have  shown,  by  means  of  careful  cardiography  tracings,  that 
the  blood  waves  in  the  coronary  arteries  and  carotids  are  exactly  synchronous  both 
in  normal  and  diseased  states  of  the  circulation. 

"It  seems  certain,  therefore,  as  Dr.  George  Balfour  and  others  have  previously 
argued,  that  the  blood  is  propelled  into  the  coronary  arteries  during  the  systole 
of  the  heart." 

Many  readers  to  whom  this  view  is  altogether  new  would  be  glad  to 
avail  themselves  of  a  reference  to  what  may  be  termed  the  bottom  facts. 

Chapter  II.  is  devoted  to  the  general  pathology  of  the  heart. 

The  accepted  doctrines  are  stated  in  a  clear,  terse,  and  practical  man- 
ner. 

In  the  third  chapter  we  find  a  well-arranged  and  suggestive  method  of 
case-taking  set  forth,  together  with  a  summary  of  symptoms  and  the 
methods  and  results  of  the  physical  examination  in  cases  of  heart  disease. 

Much  space  is  devoted  to  the  discussion  of  Cheyne-Stokes'  respiration, 
and  the  theories  that  have  been  advanced  by  Traube,  Sansom,  and  Filehne 
to  explain  the  manner  in  which  it  is  produced.  This  peculiar  rhyth- 
mical dyspnoea  is,  as  is  well  known,  an  ominous  symptom,  occurring 
usually,  but  by  no  means  exclusively,  in  advanced  cases  of  heart  disease, 
especially  of  dilated  and  fatty  right  heart,  atheroma  of  the  coronary 
arteries,  and  aortic  dilatation,  and  being  in  most  cases  followed  shortly  by 
death.  It  is  probably  to  be  accounted  for  by  the  fact  that  periodical  vari- 
ations occur  in  the  amount  of  oxygen  supplied  to  the  respiratory  centre  in 
the  medulla.  The  author's  discussion  of  this  subject  is  exceedingly 
ingenious  and  interesting.  "  The  respiratory  centre  in  the  medulla 
oblongata  probably  consists  of  two  parts — one  connected  with  inspira- 
tion (the  inspiratory  centre),  the  other  with  expiration  (the  expiratory 
centre)."  It  is,  therefore,  "  the  seat  of  two  conflicting  forces,  one  tend- 
ing to  generate  inspiratory  impulses  (the  discharging,  portion),  and  the 
other  offering  resistance  to  the  generation  of  these  impulses  (the  restrain- 
ing or  inhibiting  portion);  the  one  and  the  other  alternately  gaining  the 


198 


Reviews. 


[Jan. 


victory,  and  thus  leading  to  a  rhythmical  discharge/'  These  two  parts 
are  differently  acted  upon  by  the  same  stimulus,  venous  blood  exciting  the 
action  of  the  discharging  portion  and  depressing  the  action  of  the 
restraining  portion  ;  arterial  blood,  on  the  contrary,  depressing  the  action 
of  the  discharging  portion  and  intensifying  that  of  the  restraining  part. 
Moreover  both  these  parts  of  the  centre  are  supposed  to  be  in  a  state  of 
irritable  weakness.  Starting  then  at  the  end  of  a  period  of  apnoea,  we 
may  suppose  that  the  venous  blood  gradually  excites  a  paroxysm  of  dys- 
pnoea, (1)  by  acting  directly  upon  the  inspiratory  centre  itself,  depressing 
the  action  of  the  restraining  portion  and  arousing  the  action  of  the  dis- 
charging portion,  (2)  by  stimulating  the  action  of  the  vaso-motor  centre, 
in  consequence  of  which  the  arterioles  are  contracted  and  the  supply  of 
oxygen  to  the  respiratory  centre  is  still  further  diminished.  The  exces- 
sive irritability  of  the  discharging  portion  of  the  respiratory  centre  tends 
to  excessive  discharges  by  which  a  condition  of  dyspnoea  is  produced.  But 
in  consequence  of  its  irritative  weakness,  it  speedily  becomes  exhausted 
and  the  dyspnoea  tends  to  subside.  The  excessive  respiratory  efforts  dur- 
ing the  paroxysm  of  dyspnoea  causes  the  blood,  previously  venous,  to 
become  arterialized  ;  stimulation  of  the  discharging  portions  of  the  respira- 
tory centre  ceases  ;  stimulation  of  the  restraining  portion  is  produced  ;  and 
in  consequence  of  the  deficient  stimulation  and  over-exhaustion  of  the  dis- 
charging portion,  the  restraining  portion  has  full  swing,  and  the  condition 
of  apnoea  is  produced.  The  changes  supposed  to  take  place  during  a 
paroxysm  and  pause  of  Cheyne-Stokes'  respiration  are  illustrated  by  six 
diagrams. 

Several  pages  are  used — we  were  about  to  say  wasted — in  descriptions 
of  the  mechanism  of  the  various  forms  of  the  sphygmograph.  The  author 
gives  preference  to  Mahomed's  modification  of  Marey's  instrument,  and  to 
the  convenient  and  portable  little  instrument  of  Dudgeon.  We  confess 
that  the  latter  has  been  a  disappointment  to  us.  The  tracings  of  Pond's 
instrument,  the  mechanism  of  which  has,  with  modifications,  been  adopted 
by  Dudgeon,  are  much  more  satisfactory,  although  the  instrument  is  cer- 
tainly less  portable  and  more  delicate.  The  tracings  of  the  different 
instruments  now  in  use  are  so  different  in  certain  essential  particulars,  as 
the  relative  length  of  the  up-stroke  and  the  down-stroke,  that  we  believe 
it  would  be  a  good  rule  in  the  publication  of  cases  illustrated  by  sphyg- 
mograms  to  designate  the  instrument  used. 

The  author  holds  that  the  three  conditions  necessary  for  perceptible 
reduplication  of  the  first  sound  are  considerable  asynchronism  in  the  con- 
traction of  the  two  ventricles,  diminished  duration  of  one  or  other,  or  both 
of  the  component  parts  of  the  reduplicated  sound  and  slow  action  of  the 
heart. 

He  also  holds  the  generally  accepted  view  that  reduplication  of  the 
second  sound  is  due  to  asynchronous  closure  and  tension  of  the  aortic  and 
pulmonary  valve-flaps,  and  discusses  at  length  the  various  conditions  by 
which  such  asynchronous  action  of  the  ventricles  may  be  brought  about. 
Other  theories,  those  of  Sansom,  George  Balfour,  and  Guttmann  are  also 
given  in  brief. 

Dr.  Bramwell's  method  of  treating  the  much  vexed  and  unsettled  sub- 
ject of  functional  murmurs  partakes  more  of  the  nature  of  a  critical  review 
of  the  various  opinions  than  of  dogmatic  or  ex  cathedra  assertion.  He 
concludes,  however,  that  the  sudden  propulsion  of  a  large  blood-wave  of 
abnormal  (spanaemia)  composition  into  the  pulmonary  artery,  which  is 


1885.]    Bramyvell,  Diseases  of  the  Heart  and  Thoracic  Aorta.  199 


probably  in  many  cases  dilated,  is  an  efficient  cause  for  the  production  of 
the  basic  murmur  which  is  heard  in  the  second  left  interspace  in  the 
earlier  stages  of  anaemia.  The  italics  here  are  the  author's,  and  they 
illustrate  one  of  his  methods  of  accentuating  his  utterances. .  This  chapter 
concludes  with  brief  observations  on  the  examination  of  the  venous  system. 

With  chapter  IV.  the  study  of  the  individual  diseases  begins.  They 
are  considered  in  5  groups,  as  follows  : — 

(1)  The  diseases  of  the  pericardium. 

(2)  The  diseases  of  the  endocardium. 

(3)  The  diseases  of  the  myocardium. 

(4)  Neurotic  affections,  which  include  the  purely  functional  diseases  of 
the  organ. 

(5)  The  diseases  of  the  great  bloodvessels. 

The  congenital  malformations  of  the  heart  are  described,  contrary  to 
the  usual  arrangement,  in  their  proper  place  under  diseases  of  the  endo- 
cardium and  myocardium. 

The  section  on  pericarditis  is  well  given.  The  morbid  anatomy  is 
illustrated  by  no  less  than  eighteen  figures,  some  of  which  seem  to  us, 
however,  neither  clear  nor  necessary.  The  differential  diagnosis  is  fully 
considered,  and  for  the  most  part  by  means  of  tables  of  parallel  columns. 
The  treatment  is  up  to  date  and  ably  taught.  We  notice  upon  page  338 
the  familiar  name  of  a  distinguished  American  physician  incorrectly  spelt. 
Aspiration  of  the  effusion  is  advised  when  the  action  of  the  heart  is 
seriously  embarrassed  by  its  amount  or  the  rapidity  of  its  accumulation, 
and  life  thereby  endangered.  In  the  directions  for  the  operation  the  rules 
laid  down  by  Dr.  John  B.  Roberts,  of  Philadelphia,  are  followed.  In 
case  of  a  purulent  effusion  the  sac  is  to  be  laid  open  with  strict  anti- 
septic precautions  and  a  drainage  tube  inserted,  the  same  indications  for 
treatment  being  observed  as  in  other  internal  abscesses. 

Chapter  V.  treats  of  endocarditis  and  the  resulting  valvular  lesions. 
This  is  certainly  one  of  the  strongest  chapters  in  a  strong  book,  and  will 
take  rank  as  in  many  respects  the  best  article  upon  this  group  of  lesions  in 
any  text-book.  It  is  illustrated  by  no  less  than  sixty-six  figures,  and  takes 
up  200  pages  of  the  volume.  Acute  endocarditis  is  considered  first  in  its 
"  simple"  form,  later  in  its  ;t  ulcerative"  form.  Especial  attention  is 
directed  to  the  familiar  influence  of  absolute  rest  in  those  affections  liable 
to  endocarditis  as  a  complication  as  tending  to  avert  that  complication 
and  its  serious  results. 

Sibson's  observations  on  the  importance  of  rest  in  those  affections  are 
quoted  at  length.  The  question  of  the  treatment  of  acute  rheumatism  by 
salicin  and  the  salicylates  is  fully  discussed,  and  the  administration  of 
full  doses  of  pure  salicin  in  acute  rheumatic  endocarditis,  after  the  manner 
recommended  by  Dr.  Maclagan,  is  strongly  advised.  To  use  the  author's 
words  : — 

"  I  cannot  help  thinking  that  if  this  treatment  were  rigorously  carried  out  in 
the  earlier  stages  of  the  attack,  the  frequency  of  endocarditis  and  other  cardiac 
complications  would  be  materially  diminished." 

The  mixed  alkaline  and  salicin  treatment  is  dismissed  with  mere  men- 
tion. 

Ulcerative  endocarditis  is  not  regarded  as  a  specific  infectious  disease  in 
the  same  sense  that  typhoid,  scarlet  fever,  and  smallpox  are.  Inoculation 
experiments  have  failed  to  reproduce  the  disease.  The  clinical  history  is 
fully  given  and  the  cardiac,  typhoid,  pycemic,  and  ague-like  types  are 
described — a  clinical  subdivision  that  appears  to  us  of  questionable  utility, 


200 


Reviews. 


[Jan. 


and  as  likely  to  lead  into  as  out  of  confusion.  The  affection  is  always 
fatal,  and  the  subject  of  treatment  is  summed  up  in  a  few  discouraging 
words. 

Mitral  regurgitation  is  due  to  muscular  and  relative  incompetence  on 
the  one  hand,  and  to  organic  changes  in  the  valve  segments  on  the  other. 
The  former  is  amenable  to  treatment,  and  can  often  be  completely  cured. 
The  latter  is  incurable  ;  treatment  can  only  control  and  modify  the 
secondary  conditions  and  tend  to  establish  and  maintain  compensation. 
The  treatment  appropriate  to  each  condition  is  separately  and  clearly 
set  forth.  The  author  regards  arsenic  as  a  cardiac  tonic  of  much  value, 
which  is  too  little  used  in  the  treatment  of  mitral  regurgitation.  He 
looks  upon  digitalis  properly  used  as  the  remedy.  As  regards  the  treat- 
ment of  mitral  stenosis  : — 

"The  indications  are  the  same,  and  the  methods  of  treatment  are  similar  to 
those  which  have  been  described  as  suitable  in  cases  of  mitral  regurgitation.  I 
need  not  again  enter  into  details,  but  must  once  more  emphasize  the  statement, 
that  in  the  earlier  stages,  and  so  long  as  compensation  is  perfect,  little  or  no  drug 
treatment  is  required." 

In  aortic  incompetence  the  same  wise  general  rule  of  "  little  or  no  drug 
treatment  previous  to  failure  of  compensation,"  is  laid  down.  When  the 
left  ventricle  begins  to  fail  and  dilatation  to  replace  hypertrophy,  cardiac 
tonics  and  stimulants  are  to  be  cautiously  given.  Here  arsenic  has  seemed 
in  the  early  stages  of  the  trouble  the  most  useful  drug  both  as  a  tonic  and 
as  relieving  the  heart  pain,  which  is  a  common  attendant  of  aortic  incom- 
petence. Digitalis  when  needed  should  be  given  in  small  doses,  and  inter- 
mitted as  soon  as  its  tonic  effects  are  realized.  The  rules  for  the 
management  of  aortic  stenosis  are  the  same. 

Chapter  VI.  on  diseases  of  the  myocardium,  includes  acute  myocar- 
ditis, chronic  myocarditis  or  fibroid  degeneration,  partial  aneurism  of  the 
heart,  hypertrophy  and  dilatation  of  the  walls  of  the  several  chambers  of 
the  heart,  atrophy,  fatty  infiltration,  fatty  degeneration,  spontaneous 
rupture  and  tumors  of  the  heart. 

This  group  of  subjects  is  ably  treated,  but  without  as  far  as  we  discover 
any  extension  of  the  field  of  knowledge.  The  pathological  views  closely 
correspond  to  those  so  ably  presented  by  Dr.  W.  H.  Welch,  at  the  last 
meeting  of  the  American  Medical  Association.  The  symptomatology 
remains  obscure.  No  reference  is  made  to  the  efforts  of  Rigal  and  Jubel- 
Renoy,  in  France,  and  L.  M.  Petrone,  in  Italy,  to  clear  up  this  part  of 
the  subject  and  establish  definite  rules  for  the  diagnosis  of  myocarditis. 

Free  use  is  made  of  Wickham  Legg's  admirable  Bradshaw  Lecture  on 
Cardiac  Aneurism  (1883),  a  review  of  which  appeared  in  the  last  number 
of  this  Journal,  and  the  treatment  of  this  subject  is  both  more  extended 
and  more  satisfactory  than  in  most  text-books  on  the  heart. 

"Idiopathic"  hypertrophy  of  the  heart  scarcely  receives  the  attention 
or  space  that  it  demands.  We  are  told  that  its  occurrence  is  doubted  by 
some  observers.  The  author  holds  the  opinion  drawn  from  the  "  clinical 
examination  of  living  patients,"  that  such  cases  do  actually  occur.  The 
condition,  is,  however,  rarely  seen  on  the  post-mortem  table,  as  it  seldom 
causes  death.  The  part  played  in  the  causation  of  so-called  idiopathic 
cardiac  hypertrophy  by  alcohol,  and  in  particular  by  excessive  potations 
of  beer,  as  determined  by  Bollinger,  and  Schmidbauer,  in  Munich,  does 
not  appear  to  have  attracted  the  author's  attention.  These  observers 
attribute  the  great  frequency  of  hypertrophy  of  the  heart  without  valvular 
lesions  or  affection  of  the  kidney,  which  occurs  in  Munich,  to  the  exces- 


1885.]    Bramwell,  Diseases  of  the  Heart  and  Thoracic  Aorta.  201 


sive  habitual  consumption  of  beer  in  that  city.  Hypertrophy  is  favored 
by  the  direct  action  of  the  alcohol  upon  the  heart,  by  the  enormous  amount 
of  fluid  introduced  into  the  body,  and  by  the  readily  assimilated  nutritive 
constituents  of  the  beer  itself.  Furthermore,  such  habits  are  commonly 
associated  with  great  bodily  activity.  The  subjects  of  this  form  of  hyper- 
trophy, mostly  men,  and  often  of  middle  age,  are  always  plethoric. 
The  characteristic  changes  consist  in  the  participation  of  both  sides  of  the 
heart  in  the  overgrowth,  and  in  the  enormous  increase  in  the  volume  of 
the  primitive  muscular  elements,  with  enlargement  of  the  nuclei.  Bol- 
linger found  in  most  of  his  cases  no  anatomical  evidences  of  inflammation, 
nor  of  fatty  degeneration.  Death  takes  place  after  brief  illness,  with 
symptoms  of  cardiac  failure,  and  must  be  looked  upon  in  the  absence  of 
adequate  anatomical  lesions  as  due  to  paralysis  of  the  cardiac  nerves  and 
ganglia. 

Chapter  VIII.  treats  of  the  cardiac  neuroses,  including  palpitation,  in- 
termittent action,  and  angina  pectoris. 

The  group  of  symptoms  included  under  the  term  angina  pectoris,  are, 
in  all  probability,  produced  by  a  number  of  different  causes.  But  the 
essential  feature  of  angina  pectoris  is  pain  in  the  region  of  the  heart.  The 
cardiac  pain  often  met  with  in  young  persons,  rarely  associated  with  struc- 
tural changes  in  the  heart  or  vascular  apparatus,  and  seldom,  if  ever, 
fatal,  may  be  called  functional  angina  pectoris  (pseudo-angina).  This 
affection  is  in  strong  contrast  to  true  or  organic  angina  pectoris,  which 
rarely  occurs  before  the  fortieth  year,  is  often  associated  with  coarse  struc- 
tural changes,  very  generally  with  minute  degenerative  changes  in  the 
heart  and  vessels,  is  frequently  fatal,  in  which  the  pain  is  intense  and 
often  accompanied  by  a  terrible  sensation  of  impending  death. 

"  This  division  into  a  serious  and  organic  form,  and  a  comparatively  trivial  and 
inorganic  form,  is  of  practical  clinical  utility,  and  may  be  safely  adopted,  pro- 
vided that  it  is  clearly  understood  that  the  two  forms  run  one  into  the  other,  and 
that  it  is  sometimes  difficult  or  impossible  to  separate  them  at  the  bedside." 

We  observe  nothing  new  in  the  treatment  of  angina  pectoris,  either 
during  or  between  the  attacks. 

The  concluding  chapter  is  devoted  to  the  consideration  of  the  diseases 
of  the  thoracic  aorta.  Acute  aortitis,  atheroma  and  general  dilatation, 
aneurism,  and  coarctation  of  the  aortic  arch  are  briefly  discussed.  The 
space  given  to  aneurism  appears  to  us  meagre  in  comparison  with  the  im- 
portance of  the  subject.  This  part  of  the  book  is  very  satisfactory.  The 
remarks  upon  diagnosis  are  especially  clear  and  full.  In  the  management 
of  thoracic  aneurism  the  author  enforces  great  moderation  in  food  and 
drink,  but  does  not  regard  the  extremely  restricted  diet  of  Tufnell  as 
necessary.  Dr.  Bramwell  believes  that  the  favorable  influence  of  the 
potassium  iodide  is  due  chiefly  to  its  action  in  reducing  blood-pressure, 
and  relieving  tension  within  the  sac,  and  partly  by  removing  the  endarte- 
ritis obliterans,  which  is  often  present,  more  especially  in  syphilitic  cases, 
in  the  minute  arteries  which  ramify  in  the  walls  of  the  sac,  and  supply  it 
with  nutrient  fluid. 

The  administration  of  chloral  hydrate  in  small  doses  (seven  grains 
ter  die)  has  seemed  beneficial  in  some  cases  in  which  arterial  tension  has 
been  distinctly  increased.  The  method  of  treatment  by  galvano-puncture 
is  explained  at  length. 

The  cardiograph  is  described  in  an  appendix. 

In  conclusion,  we  commend  this  book  as  well  arranged,  clear,  trust- 
worthy, and  up  to  date.  J.  C.  W. 


202 


Reviews. 


[Jan. 


Art.  XXI  On    Tumors  of  the  Bladder,  their  Nature,  Symptoms, 

and  Surgical  Treatment.  By  Sir  Henry  Thompson,  F.R.C.S.,  M.B. 
Lond.,  Surgeon  Extraordinary  to  H.  M.  the  King  of  the  Belgians, 
Professor  of  Surgery  and  Pathology  to  the  Royal  College  of  Surgeons. 
Consulting  Surgeon  to  University  College  Hospital,  etc.  8vo.,  pp.  111. 
Philadelphia:  P.  Blakiston,  Son  &  Co.,  1884. 

The  object  of  this  book  is  to  place  before  the  profession  the  subject  of 
vesical  growths,  and  the  means  devised  and  practised  by  its  distinguished 
author  for  their  relief.  Outside  of  the  direct  domain  of  abdominal  sur- 
gery no  surgical  proceeding  has  recently  attracted  more  attention  than  the 
proposal  of  Sir  Henry  Thompson  to  freely  resort  to  a  digital  examination 
of  the  bladder  by  means  of  a  perineal  section,  whenever  there  is  ground 
from  the  history  or  symptoms  of  the  case  to  suspect  the  existence  of  a 
tumor,  which  may  possibly  be  removable. 

By  several  publications  in  various  periodicals  the  measure  has  been 
urged  by  its  author  and  his  experience  with  it  detailed,  until  it  has  become 
familiar  to  most  surgeons,  many  of  whom,  as  opportunity  has  offered, 
have  begun  to  follow  in  the  steps  of  this  greatest  living  authority  upon 
affections  of  the  urinary  organs,  and  to  put  in  force  his  suggestions  in 
their  own  practice. 

In  June  last,  Sir  Henry  Thompson  delivered  two  lectures  before  the 
Royal  College  of  Surgeons  upon  the  subject,  and  of  these  lectures,  some- 
what enlarged  and  altered  in  form,  the  present  volume  consists.  After 
commenting  upon  the  obscurity  which  so  often  attends  on  some  cases  of 
bladder  and  kidney  disease,  the  method  of  arriving  at  a  probable  diagnosis 
is  pointed  out  with  the  author's  usual  perspicuity  and  decision.  It  is  in- 
sisted upon,  that  in  every  case  we  should  inquire  into  the  frequency  of 
micturition,  whether  there  is  pain  connected  with  the  act,  and  if  so,  what 
is  its  character  and  seat,  whether  blood  has  been  seen  in  the  urine,  mixed 
or  unmixed,  at  the  beginning  or  end  of  the  act  of  urination,  and  whether 
its  presence  is  affected  by  exercise  ;  the  character  of  the  stream  passed  ; 
the  character  of  the  urine  itself  to  the  eye  and  as  determined  by  micro- 
scopical and  chemical  tests  ;  the  presence  of  pain  in  any  part  which  can 
be  connected  in  any  way  with  the  urinary  organs,  of  dropsy,  or  of  the  other 
complications  indicating  renal  disease.  The  vast  majority  of  cases  will 
be  made  clear  where  a  systematic  and  thorough  examination  is  made  upon 
these  points,  and  in  the  order  given,  but  Sir  Henry  Thompson  points  out 
that  there  are  left  some  cases  to  which  the  clue  is  not  found  even  where 
these  details  are  carefully  and  accurately  studied,  and  upon  which  even 
careful  physical  examination,  by  sounding  the  bladder,  palpating  the  ab- 
domen, and  investigating  the  condition  of  the  prostate  and  neck  of  the 
bladder  through  the  rectum,  sheds  no  light. 

The  existence  of  such  cases  and  especially  the  lesson  taught  him  by  one 
in  which  the  patient  succumbed  to  the  exhaustion  occasioned  by  a  small 
tumor,  led  Sir  Henry  Thompson  to  consider  whether  he  could  not  ex- 
plore the  bladder  during  life.  The  particular  case  referred  to  was  under 
his  care  for  several  years,  and  he  even  resorted  to  a  supra-pubic  incision, 
but  was  unable  to  detect  anything,  yet  after  death  there  was  found  a 
single  pedunculated  tumor,  which  could  have  been  easily  removed 
through  an  enlarged  incision,  and  which  by  hemorrhage  and  prolonged 
irritation  had  caused  the  death  of  a  man  only  thirty-eight  years  old,  after 
all  the  agonizing  suffering  which  attends  these  cases. 


1885.] 


Thompson,  Tumors  of  the  Bladder. 


203 


After  much  thought  he  was  led  to  question  whether  with  perfect  flacci- 
dity  of  the  abdominal  walls  induced  by  complete  anaesthesia,  he  could  not 
reach  the  entire  cystic  surface  with  his  finger  inserted  through  a  median 
incision  into  the  membranous  portion  of  the  urethra.  This  conception  he 
first  put  into  practice  in  a  case  in  which  he  suspected  the  presence  of  an 
impacted  calculus.  He  found  that  he  was  perfectly  able  to  explore  the  en- 
tire vesical  cavity,  and  finding  that  what  he  had  thought  to  be  an  impacted 
calculus  was  a  pedunculated  tumor  with  some  phosphatic  deposit  cover- 
ing it,  he  twisted  it  off  by  means  of  forceps,  the  patient  making  a  good 
recovery,  and  continuing  well  up  to  the  time  of  the  delivery  of  these  lec- 
tures. His  early  impression  was  that  it  would  be  necessary  to  incise  the 
neck  of  the  bladder,  but  experiment  upon  the  dead  body,  and  his  ex- 
perience in  this  first  case  convinced  him  that  simple  "  external  urethro- 
tomy" would  suffice.  It  is  therefore  this  old  "button  hole"  operation 
applied  for  a  new  purpose,  namely  exploration  of  the  bladder,  which  makes 
up  the  new  procedure. 

The  membranous  urethra  is  opened  in  the  usual  way  and  a  gorget-like 
director  is  insinuated  along  the  groove  of  the  staff  until  it  reaches  the 
bladder,  and  along  this  director  the  left  index  finger  is  gradually  inserted 
into  the  same  viscus.  The  surgeon  rising  from  his  seat  then  makes  firm 
pressure  upon  the  thoroughly  relaxed  abdominal  walls,  and  by  this  pres- 
sure, with  such  alterations  in  the  position  of  the  finger  as  he  is  able  to  make, 
the  whole  mucous  surface  is  successively  brought  into  contact  with  the 
finger  tip.  With  vivid  pen  the  author  of  this  book  depicts  the  enthusias- 
tic expectancy  which  waits  upon  the  surgeon  who  thus  seeks  to  lay  bare 
the  mystery  of  suffering  which  has  perhaps  persisted  for  many  years.  He 
likens  the  sensations  to  those  experienced  by  the  hunter  who  at  last  finds 
his  game  within  reach,  or  the  explorer  who  knows  that  he  is  on  the  verge 
of  a  discovery  which  will  settle  a  question  of  centuries.  Nor  do  we  think 
he  errs,  for  the  honest-minded  physician  who  recognizes  the  true  character 
of  his  profession,  and  who  sympathizes  with  the  sorrows  of  those  to  whose 
sufferings  he  is  permitted  to  minister,  may  well  rejoice  that  not  only  is  he 
adding  to  the  facts  of  human  science,  but  that  he  may  be  just  about  to 
accomplish  that  which  will  bring  relief,  and  even  life  to  his  patient. 

In  many  cases,  however,  the  result  of  the  exploration  will  be  the  find- 
ing of  a  state  of  things  which  admits  of  no  remedy,  yet  it  is  pleasant  to 
know  that,  even  when  nothing  can  be  accomplished  in  the  way  of  cure,  the 
mystery  is  solved,  and  the  thorough  drainage  of  the  bladder  effected  by 
the  operation  is  almost  always  attended  with  great  relief  to  the  sufferings 
of  the  patient,  who  may  for  a  long  time  have  been  obliged  to  resort  to  the 
use  of  a  catheter  every  two  hours  or  oftener,  and  have  hardly  known  un- 
disturbed sleep  for  more  than  an  hour  at  a  time  for  months.  After  the 
exploration  has  been  accomplished,  and  whether  any  further  operation  has 
been  done  or  not,  Sir  Henry  Thompson  recommends  that  a  soft  rubber 
tube  just  projecting  into  the  bladder  should  be  left  in  the  wound  and 
allowed  to  remain  for  a  longer  or  shorter  period,  to  secure  complete  rest 
for  the  much  tried  bladder. 

Sir  Henry  next  gives  the  results  of  forty-three  cases  in  which  he  has 
opened  the  bladder  in  the  manner  described  and  submits  the  results  to  an 
analysis.  In  twenty  cases  a  tumor  was  found,  and  these  cases  are  treated 
of  separately  in  a  subsequent  chapter,  but  experience  has  shown  Sir 
Henry  Thompson  that  in  addition  to  those  cases  in  which  the  membra- 
nous urethra  is  opened,  with  the  object  of  exploring  the  bladder,  there  are 
four  conditions  in  which  it  may  be  most  advantageously  resorted  to  as  an 


204 


Reviews  . 


[Jan. 


alleviating  and  remedial  measure.  First  it  has  been  attended  with  benefit 
in  those  cases  not  unfrequently  seen  in  which  severe  chronic  cystitis  has 
existed  for  a  long  period  without  material  cause,  such  as  stone,  stricture, 
etc.  The  second  class  includes  those  cases  of  prostatic  .hypertrophy  and 
atony  of  the  bladder,  in  which  frequent  catheterization  is  requisite,  and 
yet  in  which  that  proceeding  is  a  cause  of  continued  irritation,  and  the 
patient  is  nearly  worn  out  by  his  sufferings.  The  third  class  consists  of 
those  cases  in  which  an  impacted  calculus,  or  adherent  calculous  matter 
are  suspected,  or  revealed  by  sounding.  The  fourth  category  consists  of 
cases  in  which  there  is  painful  micturition  or. bleeding  without  other  evi- 
dence of  pathological  change.  No  less  than  six  such  cases  have  occurred 
in  Sir  Henry  Thompson's  practice,  and  he  accounts  for  them  upon  the 
theory  that  there  has  been  a  former  attack  of  cystitis,  and  a  habit  of 
frequent  micturition  has  been  acquired  which  the  patient  finds  it  impossible 
to  overcome.  Regarding  the  operation  as  involving  but  little  risk  to  life 
our  author  has  used  it  as  a  last  resort  in  these  cases,  and  always  with 
more  or  less  relief,  which  he  attributes  to  the  entire  rest  of  a  week  or 
more  secured  to  the  bladder  by  the  operation. 

In  Chapter  III.  our  author  goes  into  a  succinct  account  of  the  history  of 
bladder  tumors,  in  the  records  of  surgery,  in  museum  specimens,  and  in 
his  own  experience.  Several  wood-cuts  representing  morbid  growths  are 
given,  and  six  colored  lithographs  representing  the  microscopical  appear- 
ances of  specimens  coming  under  his  own  observation.  The  lithographs 
are  very  satisfactory  and  exhibit  the  appearance  presented  under  the 
microscope  with  rather  diagrammatic  distinctness.  We  shall  not  attempt 
to  follow  our  author  in  the  details  contained  in  this  chapter.  Suffice  it  to 
say  that  it  gives  a  good  summary  of  the  history  of  cystic  growths,  and 
furnishes,  with  all  the  minuteness  required  by  the  general  surgeon,  the 
present  state  of  our  knowledge  concerning  the  pathology  of  these  very 
troublesome  and  serious  cases. 

Chapter  IV.  is  occupied  with  the  treatment  of  tumors  of  the  bladder. 
Sir  Henry  Thompson  has  little  confidence  in  the  administration  of  astrin- 
gents internally,  being  convinced  that  the  rest  in  a  recumbent  position 
with  which  their  exhibition  is  always  combined,  has  quite  as  much  to  do 
with  stopping  the  hemorrhage  as  the  astringents  themselves.  He  places 
much  more  reliance  upon  the  injection  of  astringents  into  the  bladder 
through  a  soft  catheter.  He  has  had  considerable  success  with  perchlo- 
ride  of  iron  and  nitrate  of  silver  in  several  cases  in  which  it  was  impossi- 
ble to  do  more  than  partially  remove  existing  growths  by  operation.  His 
experience  has  been  that  with  these  agents,  especially  the  iron,  it  is  quite 
practicable  to  control  or  at  least  materially  modify  the  hemorrhage.  He 
uses  the  iron  of  the  strength  of  from  20  to  60  minims  of  the  tincture  to 
4  ounces  of  cold  water,  and  1  to  6  grains  of  nitrate  of  silver  in  the  same 
amount  of  water. 

Sir  Henry  Thompson  is  emphatically  of  the  opinion  that  when  the 
trouble,  either  by  the  general  symptoms  or  by  actual  exploration,  is  known 
to  be  of  a  malignant  character,  it  is  not  only  useless  but  injurious  to 
attempt  the  removal  of  a  growth,  though  he  is  convinced,  as  we  have 
before  had  occasion  to  say,  that  the  exploration,  by  providing  direct 
drainage,  and  securing  rest  to  the  bladder,  will  alleviate  suffering  and  pro- 
long life. 

Considerable  space  is  given  to  the  course  to  be  pursued  by  the  surgeon 
when  he  has  opened  the  membranous  urethra  and  insinuated  his  finger 


1885.] 


Thompson,  Tumors  of  the  Bladder. 


205 


into  the  bladder.  He  is  advised  to  take  plenty  of  time  to  thoroughly 
examine  the  entire  interior  of  the  viscus  and  to  carefully  ascertain,  with 
the  aid  of  the  right  hand  pressing  down  the  abdominal  walls,  the  consis- 
tency, shape,  and  location  of  the  tumor,  should  one  be  present.  Upon  the 
care  and  accuracy  with  which  this  examination  is  made  must  depend  the 
wisdom  of  the  operator's  conclusion,  and  the  facility  and  success  which 
will  attend  his  further  steps  to  attempt  the  removal  of  the  growth.  He 
should  consider  among  other  things  whether  there  will  be  a  better  pros- 
pect of  success  by  a  supra-pubic  opening,  with  which  the  incision  already 
made  need  not  in  the  least  interfere.  In  a  general  way  it  may  be  said 
that  if  the  tumor  is  polypoid  it  admits  of  removal  either  in  whole  or  in 
part,  if  the  integrity  of  the  vesical  coats  will  not  be  too  much  imperiled, 
but  if  the  substance  of  the  growth  is  hard  and  without  marked  promi- 
nences, nothing  should  be  done  further  than  to  remove  a  fragment  for 
microscopical  inspection. 

The  proposal  to  remove  bladder  growths  through  a  simple  perineal  sec- 
tion, the  boutonniere  operation,  has  been  challenged  by  Professor  Guyon, 
of  Paris,  who  maintains  that  the  supra-pubic  operation  should  always  be 
resorted  to,  but  Sir  Henry  Thompson  ably  argues  that  in  very  many  cases 
the  first  and  much  less  serious  procedure  is  amply  sufficient;  that  it  has  the 
great  advantage  of  permitting  a  thorough  exploration  of  the  bladder  ; 
that,  as  in  fully  one-half  the  cases  a  successful  removal  of  the  growth  is 
impossible,  it  is  most  important  to  obtain  this  knowledge  by  a  step  involv- 
ing as  little  risk  to  life  as  possible  ;  and  finally,  that  his  experience  sus- 
tains him  in  the  opinion  that  the  urethral  incision  permits  of  the  success- 
ful removal  of  polypoid  growths  without  danger,  while  it  does  not  prevent 
but  highly  favors  the  prospect  of  success,  should  it  be  deemed  expedient 
to  open  the  bladder  from  above.  Our  author  next  describes  and  figures 
the  various  forceps  and  other  instruments  he  has  contrived,  and  gives  de- 
tailed directions  for  their  use,  with  many  hints  and  cautions,  the  fruits  of 
his  own  experience.  We  cannot  follow  him  through  these  minutise,  nor 
is  it  necessary,  as  we  take  it  for  granted  that  no  one  will  be  likely  to  re- 
sort to  the  operation  without  first  making  himself  familiar  with  what  Sir 
Henry  Thompson  has  written  upon  the  subject. 

But  the  true  test  of  any  operation  is  the  result  which  may  be  looked  for 
to  follow-  its  adoption,  and  Sir  Henry  Thompson  devotes  the  last  ten 
pages  of  his  monograph  to  an  analysis  of  the  results  which  he  has  obtained. 
We  shall  best  aid  the  readers  of  the  American  Journal  to  occupy  a 
judicial  position  as  regards  this  procedure  by  giving  a  brief  summary  of 
the  same  analysis.  The  total  number  of  cases  in  which  an  exploratory 
operation  revealed  the  presence  of  a  tumor  was  twenty.  Two  of  the  num- 
ber were  women,  one  of  whom  died  in  three  days  with  suppression  of 
urine,  dependent,  as  the  autopsy  showed,  upon  advanced  disease  of  the 
kidneys ;  the  other  made  a  good  recovery,  and  at  the  time  of  writing  was 
practically  cured.  Of  the  eighteen  male  cases,  five  died  within  three 
weeks,  three  within  some  months,  but  in  two  of  the  last  the  fatal  ending 
was  dependent  upon  the  development  of  malignant  disease  elsewhere. 
Nine  cases  were  living  when  the  book  went  to  press.  In  one  of  these 
a  tumor  was  removed  in  the  fall  of  1882,  and  a  similar  growth  was  suc- 
cessfully removed  in  February,  1884.  In  four  cases  it  was  only  deemed 
expedient  to  attempt  the  removal  of  part  of  the  growth,  and  all  four  were 
benefited  by  the  partial  proceeding.  Of  the  remaining  four,  one  has  had 
no  return  in  four  years  ;  a  second  had  slight  symptoms  of  a  return  after 


206 


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[Jan. 


fifteen  months,  but  is  able  to  work  hard ;  a  third  is  actively  employed,  but 
shows  a  tendency  to  bleed  after  exercise,  a  year  having  elapsed  since  the 
operation ;  the  fourth  was  greatly  improved  and  able  to  resume  his  active 
life. 

It  will  thus  be  seen  that  the  prospect  of  a  complete  and  thorough  recov- 
ery is  not  very  large,  yet  the  results  should  be  regarded  as  eminently 
satisfactory  in  view  of  the  fact  justly  insisted  upon  by  Professor  Thomp- 
son, that  unassisted  by  operation,  death  with  protracted  suffering  is  cer- 
tainly inevitable  in  every  one  of  these  cases.  The  proposer  of  the  opera- 
tion reasonably  hopes  that  he  may  have  more  success  with  his  next  twenty 
cases  from  the  experience  he  has  gained  in  his  first  series.  Already  it  is 
evident  that  by  adopting  this  operation  we  may  save  life  in  a  few  in- 
stances, and  prolong  it  with  comparative  comfort  in  some  others.  Another 
result  can  also  be  claimed  for  this  operation,  which,  though  of  more  in- 
terest to  the  surgeon  than  to  his  patients,  is  not  to  be  despised,  viz.,  the 
opportunity  it  furnishes  for  adding  to  our  knowledge  of  the  pathology  of 
bladder  tumors. 

The  details  of  a  few  cases  are  given,  and  the  volume  concludes  with  an 
elaborate  table  of  the  twenty  cases  of  tumors  which  have  fallen  under  the 
observation  of  Sir  Henry  Thompson  since  he  first  conceived  and  put  in 
practice  this  exploratory  operation.  A  noticeable  feature  of  this  table  is 
the  appending  to  each  case  of  a  diagram  intended  to  show  the  shape  and 
location  of  the  tumor  as  revealed  to  the  finger  of  the  operator. 

It  remains  for  us  but  to  commend  the  book  and  the  subject  of  which  it 
treats  to  the  attention  of  the  profession,  and  to  reiterate  our  impression  of 
its  great  importance.  Nor  can  we  conclude  without  congratulating  Sir 
Henry  Thompson  upon  his  having  made  another  valuable  contribution  to 
the  resources  of  our  science  and  art.  S.  A. 


Art.  XXII — Insanity  Considered  in  its  Medico-Legal  Relations.  By 
T.  R.  Buckham,  A.M.,  M.D.  8vo.,  pp.  265.  Philadelphia  :  J.  B. 
Lippincott  &  Co.,  1883. 

The  important  subject  discussed  in  this  treatise  has,  we  think,  been 
very  ably  and  satisfactorily  handled  by  the  author.  The  acknowledged 
uncertainty  of  verdicts  in  insanity  trials,  together  with  the  general  feeling 
of  distrust  in  relation  to  judicial  decisions  in  such  cases,  is  a  source  of 
the  profoundest  solicitude  to  all  parties  interested;  and  any  new  light 
that  may  serve  to  dispel  the  cloudiness  that  too  often  environs  the  medico- 
legal relations  of  insanity  will  be  cordially  welcomed  by  the  legal  physi- 
cian. 

This  painful  uncertainty  as  to  the  result  of  insanity  trials  has  not 
escaped  the  animadversion  of  distinguished  authorities.  According  to  one, 
in  a  capital  trial,  where  insanity  is  alleged,  "  the  acquittal  or  conviction 
of  the  prisoner  is  a  matter  of  chance ;  the  issue  could  hardly  be  more 
uncertain  if  it  were  to  be  decided  by  the  tossing  up  of  a  shilling  than  by 
the  grave  procedure  of  a  trial  in  court."  Says  another  high  authority : 
"Acquittal  on  the  plea  of  insanity  is,  on  some  occasions,  a  mere  matter 
of  accident."    Dr.  Buckham  very  properly  stigmatizes  such  a  travesty 


1885.]       Insanity  Considered  in  its  Medico-Legal  Relations.  207 


of  justice  as  shocking.  "  Guilty  persons  acquitted,  and  innocent  persons 
hanged  in  the  sacred  name  of  justice,  after  an  intended  impartial  legal 
trial!" 

Doubtless,  the  reasons  for  this  "  uncertainty"  are  to  be  ascribed  to  a 
want  of  correct  appreciation  of  the  true  nature  of  insanity,  or,  as  the 
author  expresses  it,  because  "  the  real  premises  are  imperfectly  under- 
stood." Neither  the  psychical  definitions  of  insanity,  nor  the  numerous 
judicial  decisions  rendered  have  helped  to  remove  it ;  on  the  contrary, 
they  have  but  served — especially  the  latter,  by  their  extraordinary  con- 
tradiction to  one  another — to  increase  the  difficulty  of  arriving  at  a 
satisfactory  conclusion.  What,  for  example,  can  we  conclude,  when  one 
eminent  judge  affirms  what  another  equally  eminent  denies  ?  One 
authority  asserts  that  insanity  must  be  absolute  ;  another,  that  partial 
insanity  is  sufficient.  One,  that  an  insane  person  must  be  punished  as  a 
warning  to  others  ;  another,  that  punishing  an  insane  person  is  extremely 
cruel  and  inhumane.  One  affirms  that  insanity  must  be  proved  beyond  a 
doubt  ;  another,  that  preponderance  of  proof  of  insanity  is  sufficient. 
One  declares  that  the  onus  of  proof  of  insanity  rests  with  the  defence  ; 
another,  that  it  is  on  the  state.  According  to  one,  medical  opinions  and 
theories  in  insanity  cases  are  vicious;  whilst  in  the  judgment  of  another, 
medical  experts  know  all  that  is  known  on  the  subject.  One  affirms  that 
expert  testimony  is  of  high  value  ;  another,  that  it  is  worse  than  value- 
less; and  last,  but  not  least,  that  there  are  no  legal  tests  for  insanity. 

The  author  proceeds  to  discuss  the  different  theories  of  insanity, 
referring  especially  to  the  three  mentioned  by  Wharton  and  Stille,  as  the 
"  somatic  or  materialistic,"  the  "  psychical  or  metaphysical,"  and  the 
"  intermediate."  The  first  of  these — the  somatic  theory — denies  the 
existence  of  the  mind  as  a  separate  and  distinct  entity,  but  asserts  that  it 
is  a  product  or  function  of  the  brain.  The  second  theory — the  meta- 
physical— affirms  that  the  mind  is  a  distinct  entity,  and  not  dependent 
upon  the  body  for  its  existence.  The  third,  or  intermediate  theory,  was 
first  proposed  by  Messrs.  Wharton  and  Stille,  and  is  an  attempt  to  supply 
the  acknowledged  defects,  and  to  reconcile  the  admitted  inconsistencies 
of  the  two  former  hypotheses.  "  This  view,"  according  to  its  authors, 
"  attributes  to  the  body  and  soul  alike,  originative  influence  in  the  growth 
of  mental  diseases." 

Our  space  will  permit  us  but  a  glance  at  a  few  points  in  the  different 
"theories."  The  grand  difficulty  with  the  "somatic"  theory  is,  that  the 
regarding  the  mind  as  a  function  of  the  brain,  in  the  words  of  the  author, 
"  necessarily  precludes  the  possibility  of  an  independent  will ;"  and  it 
must  further  lead  logically  "  to  the  doctrine  of  absolute  irresponsibility." 
Dr.  Maudsley,  the  most  distinguished  advocate  of  this  theory,  tells  us 
that  man  has  no  free  will,  no  ability  to  "  steer  himself  or  determine  his 
course  ;"  that  "  his  destiny  is  made  for  him  by  his  ancestors,  and  that  no 
one  can  elude,  were  he  able  to  attempt  it,  the  tyranny  of  his  organ- 
ization ;"  and  that  "he  is  brought  like  an  automaton."  Now  certainly, 
if  all  this  be  true,  then  man's  responsibility  ceases.  If  he  is  not  free  to 
choose  the  good  and  reject  the  evil,  but  if  this  choice  is  predetermined  for 
him  by  "  hereditary  transmission  of  character,  then  the  irresistible  force 
or  '  destiny'  is  responsible  for  his  course,  and  not  the  individual  himself." 

Dr.  Buckham  argues  very  forcibly  and  satisfactorily  against  this  spe- 
cious doctrine,  and  whilst  he  freely  admits  the  well-known  influence  of 
heredity  in  determining  the  development  of  the  physical  and  mental,  and 


208 


Reviews. 


[Jan. 


to  a  certain  extent  even  the  moral  qualities  of  the  individual,  he  very 
properly  objects  to  the  extreme  views  held  by  the  "somatic"  school, 
which  seems  entirely  to  deny  and  ignore  the  corrective  influence  and 
powTer  of  subsequent  education  and  association.  We  think  there  can  be 
little  doubt,  if  extended  and  accurate  tabular  results  could  be  procured  of 
the  proper  training  of  the  cast-off  children  of  poverty  and  crime,  who 
have  been  subsequently  properly  cared  for,  and  surrounded  with  whole- 
some influences,  that  such  results  would  prove  that  a  large  proportion  of 
these  children  of  an  evil  "  destiny  "  had  succeeded  in  "  eluding  the  tyranny 
of  their  organization,"  and  were  rejoicing  in  their  freedom  from  this 
"hereditary  transmission  of  character." 

The  "metaphysical  or  psychical  theory"  need  not  be  specially  alluded 
to  here.  The  author  adopts  it  partially  ;  that  is,  he  considers  the  mind  to 
be  a  distinct  entity,  separate  from  the  body,  but  "that  in  this  life  the 
mind  is  wholly  dependent  for  the  manifestation  of  its  operations  on  cer- 
tain organs  of  the  body,  which  we  designate  physical  media.''''  In  other 
words,  that  in  our  present  state  of  existence,  the  mind  can  only  act 
through  the  medium  of  its  appropriate  organ,  the  sensorium.  This  idea, 
or  doctrine,  the  author  formulates  under  the  title  of  his  "  Physical  Media 
Theory,"  which  seems  to  be  a  sufficiently  good  name  to  bestow  upon  what 
many  psychologists  have  long  held  to  be  the  true  exposition  of  the  case. 
He  most  correctly  asserts  that  "the  expert,  the  medical  jurist,  and  the 
law  have  to  deal  with  the  mind  only  when  connected  with  the  body  ;  the 
individual  comprising  both  the  mind  and  the  body.  It  will  not  be  alleged 
that  the  mind,  unless  associated  with  the  body,  can  make  a  will,  or  commit 
a  crime  of  which  human  laws  can  take  cognizance,  nor  can  the  body 
without  the  mind." 

Following  out  this  line  of  reasoning,  we  must  admit  that  the  mind  can 
appreciate  external  objects  only  through  the  sensations,  i.  e.,  impressions 
received  through  vibrations  of  distinct  nerve-fibres  ;  and  as  the  elements 
of  our  experience  are  dependent  upon  sensations,  it  further  results  that  if 
the  organs  of  transmission  be  not  in  a  healthy  state,  the  impressions 
received  must  necessarily  be  abnormal.  And  by  parity  of  reasoning,  the 
mind's  manifestations  will  be  abnormal,  or  disordered,  if  the  media 
through  which  these  manifestations  take  place  are  disordered.  And  this 
admission  brings  us  to  the  last  link  of  the  chain  of  reasoning,  namely, 
that  insanity  (which  is  a  display  of  some  of  the  disordered  mental  mani- 
festations), is  to  be  regarded  not  as  a  disease  of  the  mind,  but  as  a  disease 
of  the  physical  media,  through  which  the  mind  operates. 

This  view  of  the  nature  of  insanity  we  hold  to  be  physiologically  and 
psychologically  correct :  that  it  is  not,  properly  speaking,  a  disease  of  the 
mind,  but  of  the  brain ;  and  that  the  distorted,  deranged  mental  manifes- 
tations are  the  result  of  the  diseased  media,  through  which  the  mind  is 
forced  to  act,  just  as  pure  white  light  takes  the  hue  and  complexion  of 
the  medium  through  which  it  is  transmitted.  Nor  do  we  think  that  this 
view  is  a  mere  hypothesis,  unsupported  by  abundant  proofs.  The  author 
sustains  his  theory  by  an  appeal  to  unanswerable  facts,  one  of  the  strong- 
est of  which  is  the  therapeutic  treatment  of  the  insane  by  means  of 
material  remedies.  It  is  not  conceivable  that  the  mind  can  be  affected 
directly  by  medicines.  "  The  idea  of  curing  a  diseased  incorporeal,  intan- 
gible entity  by  the  use  of  material  remedies  is  so  utterly  absurd  that  it  is 
difficult  to  suppose  a  sane  man  who  entertains  it."  But  on  the  theory  of 
diseased  media,  the  therapeutic  treatment  is  perfectly  rational. 


1885. J       Insanity  Considered  in  its  Medieo-legal  Relations.  209 


Pathological  facts  lead  us  to  the  same  conclusion.  It  is  well  known 
that  injuries  to  the  brain  frequently  lead  to  mental  derangement,  impair- 
ing sometimes  one  faculty,  sometimes  several.  The  same  result  notori- 
ously follows  diseases  of  the  brain,  as  in  inflammation  of  this  organ  or  of 
its  meninges,  in  embolism  of  its  arteries,  cutting  off  a  due  supply  of  nu- 
trition, in  tumors,  abscesses,  and  numerous  other  diseased  conditions. 
In  any  or  all  of  these  diseases,  if  the  material  cause  affecting  the  physi- 
cal media  be  removed,  the  mental  manifestations  will  recover  their  nor- 
mal condition,  or,  in  other  words,  the  insanity  is  cured.  Moreover,  it 
does  not  follow  that  because  we  cannot  always  discern  the  physical  causes 
of  mental  disorder,  these  do  not  exist,  inasmuch  as  they  may  be  so 
subtle  and  recondite  as  to  elude  our  observation. 

Another  strong  argument  in  favor  of  the  theory  we  are  advocating  is 
derived  from  the  effect  of  certain  narcotic  medicines  upon  the  brain,  pro- 
ducing, at  will,  a  series  of  mental  disturbances,  varying  from  "  maudlin 
imbecility  or  hallucinations,  to  boisterous  maniacal  ravings,  and  the  wildest 
delirium — the  complete  subordination  of  reason  and  judgment;  and  not 
only  can  these  mental  phenomena  be  produced  at  will,  and  continued  at 
pleasure,  by  the  exhibition  of  one  or  more  of  the  deliriants,  but  the 
abnormal  mental  manifestations  may  also  be  controlled  at  will  by  the  ad- 
ministration of  the  antidote  to  the  drug  used;  while  long-continued  habit- 
ual use  of  deliriants  invariably  results  in  the  impairment  of  the  mental 
faculties." 

There  remains  a  still  further,  and  we  think  unanswerable,  proof  of  this 
theory,  viz.,  that  afforded  by  the  anatomical  lesions  of  the  brain  in  cases 
of  insanity.  Modern  research  has  established  this  beyond  a  peradventure. 
By  the  aid  of  the  microscope  and  chemistry  we  have^been  enabled  not 
only  to  verify  the  direct  connection  of  insanity  with  disease  of  the  brain, 
but,  in  numerous  instances,  to  trace  the  different  forms  of  insanity  to 
abnormal  conditions  of  different  nerve  centres.  That  this  cannot  yet  be 
done  in  every  case  of  mental  derangement  is  surely  no  argument  against 
the  position  taken,  inasmuch  as  we  are,  so  to  speak,  only  on  the  threshold 
of  research  in  this  most  interesting  field,  which  is  now  being  so  success- 
fully cultivated  by  patient  and  indefatigable  workers. 

The  chapter  on  "  Experts  in  Insanity  "  is  very  full,  and  carefully  writ- 
ten, but  we  have  room  for  only  a  very  scanty  analysis  of  its  contents. 
The  author  very  justly  takes  exceptions  to  the  employment  of  mere 
general  practitioners  as  such  experts,  restricting  the  latter  exclusively  to 
such  physicians  as  have  made  a  special  study  of  insanity,  and  preferably 
to  "  superintendents  and  first  assistants  of  State  Institutions  for  the 
Insane."  He  also  inveighs  very  properly  against  the  almost  universal 
neglect  of  the  study  of  medical  jurisprudence,  including,  of  course,  in- 
sanity, by  the  medical  colleges  of  this  country,  and  declares  that  by 
"  experts"  alone — true  experts — and  not  by  the  courts,  should  the  ques- 
tion of  the  insanity  of  the  prisoner  be  determined.  He  very  justly  con- 
demns the  vicious  practice  of  conducting  such  trials  by  presenting 
hypothetical  cases  to  the  expert,  instead  of  allowing  him  the  opportunity 
to  personally  examine  the  alleged  lunatic,  and  thus  form  a  rational  diag- 
nosis of  his  case.  He  elaborates  an  excellent  practical  scheme  for 
improving  our  present  faulty  system  of  expert  testimony  in  cases  of 
insanity,  which  contain  suggestions  well  worthy  of  consideration  by 
jurists  and  legislators.  He  concludes  with  an  "Appendix  of  Judges' 
Opinions,"  in  which  is  presented  a  truly  formidable  array  of  legal  deci- 
No.  CLXXVII.— Jan.  1885.  14 


210 


Reviews. 


[Jan. 


sions  of  the  most  startling  contradictory  characters,  delivered  by  judges 
of  equal  eminence  both  in  Great  Britain  and  in  this  country.  It  is 
almost  painful,  and  certainly  humiliating,  to  read  over  this  exhibit  of 
contradictory  judicial  rulings  on  the  various  points  connected  with  insanity 
in  criminal  trials.  Talk  about  the  disagreement  of  doctors !  why,  it 
hardly  amounts  to  a  tithe  of  what  is  here  shown  to  exist  in  the  legal  pro- 
fession. 

The  book  is  very  handsomely  printed,  and  is  provided  with  a  copious 
index.  We  can  heartily  recommend  it  as  worthy  of  perusal  by  members 
of  both  the  professions  of  medicine  and  law.  J.  J.  R. 


Art.  XXIII. —  Osteotomy  and  Osteoclasis  for  Deformities  of  the  Lower 
Extremities.  By  Charles  T.  Poore,  M.D.,  Surgeon  to  St.  Mary's 
Free  Hospital  for  Children,  New  York  ;  Member  of  the  New  York 
Surgical  Society,  etc.  8vo.  pp.  183.  New  York:  D.  Appleton  &  Co., 
1884. 

Under  the  above  title  the  author  has  presented  a  very  valuable  treatise 
upon  a  subject  which  has  during  the  last  few  years  excited  much  attention 
in  the  surgical  profession  both  abroad  and  in  this  country. 

Dr.  Poore  first  considered  the  causes  which  produce  the  deformities  for 
which  osteotomy  and  osteoclasis  may  be  required,  and  holds  with  many 
other  high  authorities  that  the  cases  are  generally,  with  the  exception  of 
a  few  due  to  coxalgia,  the  result  of  rachitis;  and  states  very  distinctly 
that  he  is  not  a  believer  in  the  spontaneous  cure  of  bending  of  the  bones, 
and  enters  his  protest  against  the  advice  which  is  frequently  given  to 
parents,  even  by  members  of  the  medical  profession,  not  to  submit  such 
cases  to  treatment,  as  they  will  outgrow  the  malposition. 

The  subject  of  osteotomy  in  general  is  next  considered,  and  there  is 
given  a  clear  and  condensed  resume  of  the  various  operations  and  their 
modifications  down  to  the  present  time,  and  there  is  added  a  description 
of  the  instruments  used  in  the  performance  of  this  operation. 

The  two  methods  of  osteotomy,  the  linear,  which  he  considers  practically 
a  subcutaneous  operation,  and  the  cuneiform,  which  is  performed  through 
an  open  wound,  are  described  and  compared,  and  the  author  expresses  his 
preference  for  the  former  as  being  attended  with  much  less  risk,  and 
equally  favorable  results  in  the  vast  majority  of  cases. 

Osteotomy  for  deformities  of  the  hip-joint  receives  a  very  extended 
notice,  and  among  the  causes  producing  these  deformities  he  mentions  hip- 
joint  disease,  rheumatism,  unreduced  dislocation,  and  fracture  united  at  an 
angle. 

For  the  correction  of  deformities  at  the  hip-joint  following  suppurative 
coxalgia,  he  unhesitatingly  recommends  osteotomy  in  preference  to  forcible 
straightening,  and  instances  examples  of  the  most  unfortunate  results 
which  have  attended  the  latter  procedure. 

The  first  osteotomy  for  deformity,  which  was  performed  by  Dr.  J.  Rhea 
Barton  in  1826,  an  anchylosis  of  the  hip  at  a  right  angle,  consequent  upon 
inflammation  of  that  articulation,  is  mentioned,  and  Dr.  Poore  then  gives 


188/5.] 


Poore,  Osteotomy  and  Osteoclasis. 


211 


a  very  interesting  account  of  the  operations  devised  by  various  surgeons 
from  that  time  to  the  present,  and  expresses  his  decided  preference  for  the 
procedure  which  is  known  as  Gant's  modification  of  Adams's  operation,  in 
which  the  section  of  the  femur  is  made  below  the  lesser  trochanter,  as  by 
all  means  the  best  operation  in  cases  of  deformity  due  to  hip-joint  disease. 

Mr.  Adams's  operation,  that  is,  section  of  the  neck  of  the  femur,  he  con- 
siders a  good  operation  when  the  bone  is  in  a  healthy  condition,  to  correct 
such  a  deformity  for  instance  as  might  arise  from  acute  traumatic  inflam- 
mation of  the  hip-joint.  In  his  preference  for  subtrochanteric  osteotomy 
to  that  of  the  neck  or  to  the  intertrochanteric  section  of  the  femur,  in 
cases  of  deformity  resulting  from  coxalgia,  the  present  writer  most  heartily 
concurs,  as  may  be  seen  by  reference  to  a  paper  upon  this  subject  published 
in  The  American  Journal  of  the  Medical  Sciences  for  July,  1883, 
page  101.  The  mortality  for  167  cases  of  osteotomy  at  the  hip  collected 
by  Dr.  Poore  is  given  at  10.18  per  cent.;  this  includes  35  cases  of  cunei- 
form section,  68  cases  of  section  through  the  neck  of  the  bone,  and  64 
cases  of  section  below  the  trochanters.  This  high  rate  of  mortality  is 
explained  upon  the  ground  of  imperfect  knowledge  as  to  the  steps  of  the 
operation  and  the  selection  of  proper  cases,  as  instanced  by  the  greater 
number  of  fatal  cases  in  the  early  history  of  the  operation. 

We  confess  that  we  were  much  surprised  to  find  so  high  a  mortality 
following  this  operation,  for  our  experience  of  the  cases  in  which  it  has 
been  performed  in  this  city,  and  we  have  cognizance  of  some  twenty  cases 
not  one  of  which  terminated  fatally,  would  lead  us  to  consider  it  one  of  the 
safest  of  surgical  procedures. 

In  this  operation  Dr.  Poore  uses  the  osteotome  or  chisel  in  preference 
to  the  saw  devised  by  Mr.  Adams,  thinking  that  the  former  makes  a 
cleaner  wound,  and  one  which  heals  more  readily  ;  in  this  respect  he 
agrees  with  the  late  Mr.  Maunder,  but  here  also  we  must  confess  that  we 
have  been  abundantly  satisfied  with  the  results  following  the  use  of  the 
saw,  and  consider  it  a  most  satisfactory  instrument. 

The  accidents  recurring  after  this  operation .  have  been  few;  among 
these  may  be  mentioned  excessive  suppuration,  occasionally  hemorrhage, 
in  one  case,  which  ended  in  recovery  after  ligation  of  the  femoral  artery ; 
gangrene,  which  terminated  fatally,  from  the  great  vessels  being  caught 
over  the  upper  fragment  of  the  bone,  and  division  of  the  great  sciatic 
nerve  during  an  intertrochanteric  section. 

The  subject  of  genu  valgum,  is  considered  very  fully,  the  author  believ- 
ing in  the  now  universally  adopted  osseous  theory  of  its  production.  He 
describes  three  varieties  of  genu  valgum,  a  femoral  form  in  which  the 
deformity  is  due  to  changes  in  the  relation  of  the  condyles  of  this  bone  ;  a 
tibial  form,  in  which  the  malposition  of  the  leg  is  due  to  changes  in  the 
plane  of  the  tibial  heads,  and  a  tibial  form  jn  which  the  articular  ends  of 
both  bones  may  be  so  altered  that  both  contribute  to  produce  the  defor- 
mity. He  attributes  the  greater  number  of  deformities  to  the  femoral 
form  in  which  there  is  hypertrophy  of  the  internal  condyle  of  the  femur. 

The  various  operations  devised  for  the  relief  of  this  deformity  are  fully 
described,  and  the  unsatisfactory  results  of  mechanical  treatment  alone 
are  pointed  out ;  the  author  very  strongly  advocates  the  operation  of  Mac- 
ewen,  that  is,  a  transverse  section  of  the  shaft  of  the  femur  through  a  small 
wound  from  the  inner  side  a  short  distance  above  the  epiphyseal  line  of 
that  bone. 


212 


Reviews. 


[Jan. 


The  vast  number  of  cases  operated  upon  by  Macewen  with  very  satis- 
factory results  in  removing  the  deformity,  and  with  an  almost  insignificant 
mortality,  fully  justifies  the  favorable  opinion  expressed  by  Dr.  Poore  ; 
and  a  limited  number  of  cases  of  this  operation,  which  have  come  under 
our  observation,  incline  us  to  hold  the  same  opinion. 

Osteotomy  for  Genu  Varum  and  Tibial  Curves  is  also  fully  described 
and  illustrated  by  appropriate  cases ;  here  also  some  personal  experience 
induces  us  to  accept  the  views  of  the  author  as  to  the  general  safety  and 
remarkably  successful  results  of  this  operation  in  properly  selected 
instances. 

The  after-treatment  of  cases  which  have  been  subjected  to  the  opera- 
tion of  osteotomy  is  laid  down  in  a  most  clear  manner ;  the  small  wound 
through  which  the  bone  has  been  divided  is  first  closed  by  a  narrow  strip  of 
adhesive  plaster  and  a  compress  covered  with  iodoform  is  next  applied  ; 
the  limb  is  then  put  up  in  plaster-of-Paris  dressing,  which  gives  very 
firm  fixation  to  the  parts  ;  on  the  third  or  fourth  day  a  trap  is  cut  opposite 
the  wound,  or  sooner,  if  there  be  a  rise  of  temperature,  and  the  wound  can 
be  dressed  through  this  if  any  suppuration  has  occurred,  but  the  wounds 
are  more  often  found  perfectly  healed  at  their  first  exposure.  In  cases  of 
osteotomy  of  the  upper  portion  of  the  femur  the  wound  is  treated  in  the 
same  manner,  but  a  splint  and  extension  apparatus  are  applied  instead  of 
the  plaster-of-Paris  dressing. 

Osteoclasis,  both  manual  and  instrumental,  are  fully  described,  and 
the  variety  of  cases  suitable  for  their  application  are  pointed  out,  as  well 
as  some  of  the  instruments  which  have  proved  most  useful  for  this 
purpose. 

The  Redressement  brusque  of  Guerin  and  Delore  is  also  described  in  its 
relation  to  the  correction  of  deformities  of  the  lower  extremity ;  and  the 
author  points  out  the  preference  of  the  French  school  of  surgeons  for  osteo- 
clasis in  some  of  its  forms  to  osteotomy,  which  finds  more  advocates  among 
the  English  and  German  surgeons. 

On  the  whole,  the  author  expresses  himself  well  satisfied  with  the  oper- 
ation of  osteoclasis  as  being  an  operation  attended  by  little  risk,  and  one 
which  is,  in  suitable  cases,  followed  by  most  satisfactory  results ;  he  has 
made  use  of  this  procedure  in  34  limbs  with  success  as  regards  the  correc- 
tion of  the  deformity  and  without  any  untoward  consequence.  In  cases 
not  suitable  for  osteoclasis  he  recommends  linear  or  cuneiform  osteotomy, 
preferring  the  former  when  practicable  as  the  safer  operation  ;  this  is  well 
shown  by  the  following  statistics :  1448  linear  osteotomies  gave  a  mor- 
tality of  0.01  per  cent.,  while  62  cuneiform  osteotomies  gave  a  mortality  of 
0.96  per  cent. 

Dr.  Poore  has  had  quite  a  large  personal  experience  with  the  various 
operations  for  the  correction  of  deformities  of  the  bones,  and  has  embodied 
the  results  of  that  experience  in  this  very  practical  and  interesting  treatise, 
which,  we  doubt  not,  will  be  well  received  and  studied  with  profit  by  the 
medical  profession.  H.  R.  W. 


1885.]    Recent  Works  on  Albuminuria  and  the  Testing  of  Urine. 


213 


Art.  XXIV. — Recent  Works  on  Albuminuria  and  the  Testing  of  Urine. 

1.  On  the  Various  Modes  of  Testing  for  Albumen  and  Sugar  in  the 

Urine.    Two  lectures  by  George  Johnson,  M.D.   London,  1881. 

2.  On  Bedside  Urine  Testing,  including  Quantitative  Albumen  and 

Sugar.    By  George  Oliver,  M.D.,  2d  ed.    London,  1884. 

3.  Discussion  on  Albuminuria,  its  Pathology  and  Clinical  Signifi- 

cance, before  the  Glasgow  Pathological  and  Clinical  Society.  Re- 
printed from  the  Glasgow  Medical  Journal.    Glasgow,  1884. 

It  may  be  said  without  exaggeration,  that  whatever  is  worth  knowing 
about  albuminuria  is  contained  in  the  three  small  volumes  above  named. 
It  is  true  that  the  reader  who  has  perused  them  all  may  be  in  some 
uncertainty  in  view  of  the  large  number  of  facts  which  are  there  brought 
to  his  notice,  as  to  exactly  what  ought  to  be  remembered.  Only  a  few 
years  ago  it  would  have  been  thought  scarcely  possible  that  so  much 
new  information  could  have  been  gathered  upon  this  important  subject, 
in  connection  with  the  tests  for  it,  the  mechanism  of  its  production,  and 
its  bearing  upon  health  and  disease.  Unfortunately,  as  is  so  often  the 
case,  when  a  mass  of  new  facts  are  adduced  upon  a  given  subject,  there 
are  some  discrepancies  in  the  results  of  different  observers,  which  time 
and  further  experience  must  reconcile. 

Dr.  Johnson's  admirable  little  book  is  practically  an  appeal  for  picric 
acid  for  the  first  place,  not  only  as  an  albumen  test,  but  also  as  a  delicate 
test  for  sugar,  although  other  methods  of  testing  for  albumen  and  sugar 
are  also  considered.  He  demonstrates  the  usual  fallacies  and  defects  of 
the  heat  and  nitric  acid  tests,  and  calls  attention  to  a  source  of  error 
which  is  not  commonly  appreciated.  It  is  the  practice  of  adding  acetic 
acid  to  the  urine  before  boiling,  as  the  result  of  which  an  acetate  of  albu- 
men is  formed,  which,  like  the  nitrate  of  albumen,  is  not  coagulable  by 
heat.  The  albumen,  therefore,  remains  in  solution,  and  is  not  detected. 
This  statement  of  Dr.  Johnson  is  confirmed  by  our  own  experience. 

Dr.  Johnson  very  properly  insists  that  the  smallest  amount  of  albumen 
detectable,  whether  accompanied  or  not  by  the  presence  of  tube-casts,  is 
abnormal.  For  its  detection,  into  a  test-tube  six  inches  long,  he  pours  a 
four-inch  column  of  urine;  then  holding  the  tube  in  a  slanting  position, 
he  gently  pours  an  inch  of  the  saturated  picric  acid  solution  on  the 
surface  of  the  former,  where,  in  consequence  of  its  low  specific  gravity 
(1005),  it  mixes  only  with  the  upper  layer  of  the  urine.  As  far  as 
the  yellow  color  of  the  picric  acid  solution  extends,  the  coagulated  albu- 
men renders  the  liquid  turbid,  contrasting  with  the  transparent  unstained 
urine  below.  There  must  be  an  actual  mixture,  and  not  merely  a  surface 
contact  of  the  two  liquids.  "When,  in  consequence  of  the  scantiness,  the 
turbidity  is  slight,  the  application  of  heat  to  the  upper  part  of  the  turbid 
column  increases  the  turbidity.  If  the  tube  be  then  placed  aside,  in  the 
course  of  an  hour  a  delicate  horizontal  film  will  have  formed  at  the  junc- 
tion of  the  colored  and  unstained  strata  of  urine. 

Another  method  recommended  by  Dr.  Johnson,  is  to  add  about  one- 
third  of  a  grain  of  powdered  picric  acid,  or  as  much  as  can  be  carried  on 
the  point  of  a  penknife,  to  about  a  drachm  of  urine  in  a  test-tube.  As 
the  picric  acid  dissolves,  the  urine  becomes  turbid  in  proportion  to  the 
amount  of  albumen. 


214 


Reviews. 


[Jan. 


The  albuminous  opalescence,  which  always  occurs  immediately  if  at 
all,  and  is  increased  by  heat,  may  easily  be  distinguished  from  the  coarse 
granular  particles  of  urate  of  sodium,  which  sometimes  result  from  the 
acidity  of  the  picric  solution,  since  they  are  readily  dissipated  by  heat. 
If  left  alone  they  also  fall  quickly  to  the  bottom,  carrying  with  them  so 
much  of  the  picric  coloring  matter,  that  when  placed  under  the  micro- 
scope they  are  so  opaque  as  to  appear  almost  black. 

In  like  manner,  peptones,  quinine,  and  the  other  vegetable  alkaloids, 
which  are  precipitated  by  picric  acid,  are  redissolved  on  the  application 
of  heat.  In  fact,  says  Dr.  Johnson,  "  there  is  no  known  substance  occur- 
ring in  either  normal  or  abnormal  urine,  except  albumen,  which  gives  a 
precipitate  with  picric  acid  insoluble  by  the  subsequent  application  of 
heat."  Further,  out  of  some  hundreds  of  specimens  of  urine  he  has 
tested  for  peptones,  he  has  found  them  in  only  one  specimen,  which  Avas 
sent  to  him  by  Dr.  Oliver. 

Dr.  Johnson  believes,  too,  that  picric  acid  is  a  much  more  delicate  test 
for  peptones  than  Fehling's  copper  solution,  which  has  been  chiefly  re- 
lied on.1 

While  peptones  and  urates  are  redissolved  by  applying  heat,  both  are 
redeposited  on  cooling,  when  the  urates  are  revealed  by  the  micro- 
scope to  be  composed  of  large  granules  of  sodium  urate  and  uric  acid 
crystals,  while  the  peptones  appear  as  exceedingly  minute  granules, 
which  exhibit  the  Brownian  movement.  If  peptones  are  associated  with 
albumen  in  the  same  specimen,  their  detection  and  separation  may  be 
readily  effected  by  the  picric  acid  and  heat  tests.  The  precipitate  with 
picric  acid,  instead  of  being  increased  and  rendered  dense  by  heat,  as 
when  albumen  alone  is  present,  will  be  lessened  in  proportion  to  the 
peptones  present.  If  the  boiling  liquid  be  then  poured  on  a  filter,  the 
dissolved  picrate  of  peptones  will  pass  through  and  precipitate  again  on 
cooling,  while  the  coagulated  albumen  remains  on  the  filter. 

Dr.  Johnson  considers  the  addition  of  citric  acid  to  the  picric  solution, 
as  suggested  by  Dr.  Oliver,  unnecessary.  This  may  be  so,  but  it  is  never- 
theless true,  as  Dr.  Oliver  says,  that  the  picric  cum  citric  solution  is  more 
delicate  than  the  picric  alone.  That  is,  in  testing  very  small  albuminurias, 
we  have  found  the  picric  acid  solution  to  which  citric  acid  has  been  added 
in  the  proportion  of  two  drachms  to  the  ounce  of  the  former  to  produce 
a  broader  and  more  distinct  line  when  used  by  the  contact  method  than 
does  the  pure  picric  acid  solution.  At  the  same  time,  while  the  urine 
experimented  with  was  one  which,  although  it  contained  numerous  hya- 
line tube-casts,  did  not  respond  to  the  heat  and  pure  acid  tests,  the  line 
produced  by  the  picric  solution  was  as  distinct  as  any  one  could  desire. 
Another  advantage,  also,  of  the  mixed  picric  and  citric  solution  is  the 
fact  that  it  is  heavier  than  any  urines  likely  to  be  met  with;  and,  there- 
fore, may  be  placed  first  in  the  test-tube  and  overlaid  with  urine  ;  while 
the  pure  picric  acid  solution,  which  has  a  specific  gravity  of  1005,  is  lighter 
than  most  urines,  and  must,  therefore,  be  poured  on  the  urine.  Again,  a 
urine  may  be  so  light  as  to  be  of  the  same  specific  gravity  as  the  picric 
solution,  when  it  is  impossible  to  overlay  at  all,  the  two  fluids  mixing 
immediately.  This  is  by  no  means  unimportant,  because  it  seems  to  be 
conceded  by  all  observers  that  the  ';  contact  method"  is  that  which  in- 

1  If  urine  is  gently  poured  on  the  surface  of  some  Fehling's  solution  previously 
introduced  into  a  test-tube,  a  rose-red  color  appears  at  the  junction  of  the  two  liquids 
if  peptones  are  present. 


1885.]    Eecent  Works  on  Albuminuria  and  the  Testing  of  Urine.  215 


sores  the  greatest  delicacy  with  all  the  so-called  delicate  tests,  and  with- 
out which  most  of  them  can  scarcely  be  called  delicate. 

Dr.  Oliver's  little  book,  which  reached  a  second  edition  within  a  twelve 
month  after  it  first  occurred  to  him  to  facilitate  urinary  examination  at 
the  bedside  by  means  of  test-papers,  is  ostensibly  devoted  to  this  subject, 
but  contains  much  valuable  information  quite  independent  of  it,  includ- 
ing quantitative  methods  for  albumen  and  sugar,  also  by  means  of  test- 
papers. 

In  Dr.  Oliver's  experience  with  the  delicate  tests  he  found  the  potassio- 
mercuric  iodide,  sodium  tungstate,  the  picric  cum  citric  and  the  picric 
acids  the  readiest ;  and  he  would,  if  asked  for  a  preference,  decide  in  favor 
of  the  first.  He  found  the  nitric  acid,  acidulated  brine  of  Dr.  Roberts, 
and  potassium  ferrocyanide,  much  slower  in  bringing  to  light  mere  traces 
of  albumen.  In  the  form  of  a  test-paper,  Dr.  Oliver  found  the  picric  acid 
"  the  weakest  of  the  series."  In  reply  to  this,  Dr.  Johnson  says  the  small 
slips  of  paper  dried  after  immersion  in  a  saturated  solution,  do  not  retain 
sufficient  to  render  them  a  satisfactory  means  of  testing.  But  the 
ferro-cyanide  of  potassium,  although  much  less  delicate  than  the  others 
mentioned,  is  the  only  one  of  the  series  besides  heat  and  nitric  acid 
which  does  not  throw  down  peptones.  For  previous  acidulation  of  the 
urine,  Dr.  Oliver  invariably  uses  citric  acid,  w7hich  in  the  case  of  the 
potassio-mercuric  iodide  and  potassium  ferrocyanide  is  placed  in  a  separate 
test-paper,  which  may  be  attached  by  a  thin  layer  of  rubber  to  the  paper 
containing  the  reagent.  This  may  be  done  in  the  case  of  the  picric  acid 
and  sodium  tungstate,  although  with  them  chemical  reasons  do  not  neces- 
sitate the  separation  of  the  citric  acid  from  the  reagent,  and  the  two  are, 
therefore,  united  in  the  same  paper. 

It  is  to  be  remembered  that  all  of  these  tests  may  produce  an  opacity 
by  the  precipitation  of  acid  amorphous  urates,  that  all  except  the  sodium 
tungstate  and  ferrocyanide  of  potassium  precipitate  the  vegetable  alka- 
loids, and  all  but  the  ferrocyanide  throw  down  peptones  ;  but  the  opacity 
thus  produced  is  promptly  dissipated  by  moderate  heat.  The  oleo-resins, 
as  balsam  of  copaiba,  are  precipitated  by  citric  and  picric  acids,  but  dis- 
appear on  boiling  to  quickly  reappear,  even  before  the  urine  is  quite 
cooled.  The  others  of  the  series  do  not  precipitate  the  oleo-resins,  in  the 
absence  of  citric  acid. 

Mucus  is  promptly  precipitated  by  citric  acid,  and  if  this  is  added 
first,  as  directed  by  Dr.  Oliver,  the  pressure  of  mucus  is  revealed  at 
the  onset;  and  it  may  be  filtered  out.  The  mucus  thus  precipitated  is 
insoluble  by  heat,  and  is  thus  distinguished  from  urates.  Heat,  on  the 
other  hand,  intensifies,  the  albumen  precipitates.  Dr.  Kirk  in  his  paper 
before  the  Glasgow  Medical  Society  also  suggests  the  use  of  citric  acid  to 
remove  mucus. 

With  regard  to  quantitative  testing  for  albumen,  while,  as  far  as  we 
know,  Dr.  Oliver's  method  is  the  shortest  and  simplest  yet  suggested,  we 
think  it  still  too  troublesome  to  be  much  availed  of  by  the  practising 
physician,  and  quite  agree  with  Dr.  Johnson,  that  for  practical  purposes  it  is 
sufficient  to  use  the  term  "  opalescence"  for  the  slightest  degree  of  coagu- 
lation, "milkiness"  for  a  greater  degree  of  turbidity,  and  to  indicate  still 
larger  amounts  by  fractions  showing  the  proportion  of  the  bulk  of  albumen, 
after  subsidence,  to  the  whole  column  of  fluid  tested,  as  J,  etc.  The 
latter  mode  of  measurement  may  be  carried  to  a  considerable  degree  of 


216 


Reviews. 


[Jan. 


refinement  by  using  suitably  graduated  test-tubes.  Under  these  circum- 
stances, at  least  six  hours  should  be  allowed  for  subsidence. 

The  discussion  on  Albuminuria  before  the  Glasgow  Pathological  and 
Clinical  Society  is  a  12mo.  volume  of  164  pages,  made  up  of  excellent 
papers,  not,  of  course,  unconflicting,  or  without  error,  but  reflecting,  every 
one,  a  high  degree  of  intelligence,  and  a  thorough  acquaintance  with 
urinary  pathology.  It  is  of  course  impossible  for  us  to  give  even  an  out- 
line of  the  views  expressed  by  the  different  speakers,  who  included  Dr. 
Roberts,  of  Manchester,  Profs.  Gardner,  Greenfield,  McCall  Anderson, 
Hamilton,  Cleland,  Leishman,  and  Drs.  David  Newman,  J.  Mortimer 
Granville,  Mahomed,  Finlayson,  Coats,  McGregor-Robertson,  Kirk, 
Perry,  Middleton,  and  Steven;  while  papers  by  Drs.  George  Oliver  and 
Francis  Henderson  were  held  as  read  in  their  absence,  and  published. 
It  is»but  right  to  say,  that  some  of  the  strongest  papers  were  read  by  men 
whose  names  are  least  known. 

We  were  somewhat  surprised  to  find  Drs.  Newman  and  Middleton 
adopting  the  view  originally  suggested  by  von  Wittich,1  according  to 
which  the  urine  is  formed  in  the  first  place  by  a  filtration  into  the  Malpi- 
ghian  capsule  of  the  serum  of  the  blood,  including  the  albumen,  and  that 
the  act  is  completed  by  the  reabsorption  of  the  albumen  by  the  cells  of  the 
convoluted  portions  of  the  uriniferous  tubules.  This  view  we  first  met 
fully  developed  in  the  Manual  of  Physiology,  by  Kiiss,  of  which  a  trans- 
lation by  Dr.  Amory,  of  Boston,  was  published  in  this  country  in  1875. 
The  strongest  argument  in  favor  of  it  is  the  very  satisfactory  manner 
in  which  it  explains  the  existence  of  the  so-called  normal  or  physiolo- 
gical albuminuria,  but  as  we  agree  with  Dr.  Johnson  and  others,  that  no 
albuminuria  can  be  physiological,  although  there  may  be  an  albuminuria 
which  is  of  comparatively  small  significance,  this  prop  of  the  von  Wittich's 
theory  is  removed. 

The  most  important  point  in  Dr.  Roberts's  paper  is  the  conclusion  to 
which  he  has  come,  that  the  heat  test  remains  in  his  hands  the  most  deli- 
cate. But  it  appears  to  us,  as  to  Dr.  McCall  Anderson,  the  president, 
that  Dr.  Kirk  has  thoroughly  vindicated  the  delicacy  of  the  picric  acid 
test  when  used  in  the  "  contact  method"  as  suggested  by  Dr.  Johnson,  and 
we  can  say  also  with  Dr.  Anderson,  that  "  we  know  no  more  beautiful  or 
more  delicate  test  for  albumen  than  the  picric  acid  solution." 

Both  Dr.  Johnson's  and  Dr.  Oliver's  books  include  sugar  testing.  The 
former  gives  the  preference  over  all  other  tests  to  picric  acid,  for  quan- 
titative and  qualitative  testing.  Being  more  delicate  than  Moore's  test, 
the  fermentation  test,  and  Trommer's  test,  it  is  at  least  as  delicate  as 
Fehling's  cupric  fluid  and  Pavy's  ammonio-cupric  method,  while  it  re- 
quires less  manipulative  skill,  is  more  rapidly  completed,  and  is  not 
affected  by  albumen,  uric  acid,  or  other  ingredient  of  the  urine. 

We  must  refer  the  reader  to  Dr.  Johnson's  own  book  for  the  details  of 
the  quantitative  method  by  picric  acid,  but  subjoin  the  method  by  which 
he  tests  every  specimen  of  urine  qualitatively,  first  for  albumen,  and  then 
for  sugar.  To  about  a  drachm  of  urine,  add  its  own  volume  of  saturated 
picric  acid  solution.  If  the  liquid  remains  clear,  no  albumen  is  present. 
If  a  precipitate  occurs,  not  dissolved  by  boiling,  there  is  albumen  in  pro- 
portion to  the  amount  of  precipitate.  Now  add  half  a  drachm  of  liquor 
potassse,  and  boil  for  a  few  seconds ;  the  coagulated  albumen  if  present,  is 


1  Ueber  Harnsecretion  und  Altmminurie,  Yirchow's  Archiv,  Bel.  x.,  s.  325,  1856. 


1885.]    Recent  Works  on  Albuminuria  and  the  Testing  of  Urine.  217 


dissolved  by  the  alkali,  and  a  red-black  coloration  occurs.  If,  when  an 
ordinary  half  inch  test-tube  is  held  up  to  the  light,  a  red  color  is  visible 
through  the  liquid,  there  is  no  more  than  the  normal  amount  of  saccharine 
matter — less  than  a  grain  to  the  ounce.  As  little  as  two  grains  to  the  ounce 
will  render  the  liquid  inky-black,  so  that  no  light  is  transmitted  through 
the  tube. 

Dr.  Johnson  believes,  with  many  others,  that  there  is  a  trace  of  glucose 
or  some  allied  substance  in  normal  urine,  which  gives  a  reaction  alike 
with  picric  acid  and  Fehling's  solution.  He  finds  the  results  with  the 
two  tests  remarkably  uniform,  that  with  picric  acid  indicating  a  little 
less,  .5  to  .7  of  a  grain  to  the  ounce,  and  Fehling's  solution,  .7  to  .9  of  a 
grain.  We  think  there  is  reason  to  believe  that  such  reaction  with  Feh- 
ling  in  normal  urine  is  due  to  uric  acid,  and  possibly  in  part  to  kreatinin; 
and  that  when  these  substances  are  carefully  removed,  no  reaction  occurs 
with  Fehling.  Dr.  Johnson  is  sustained  in  his  position  that  uric  acid 
does  not  react  with  picric  acid,  by  the  results  of  Dr.  Oliver's  experi- 
ments ;  but  the  latter  has  found  that  both  kreatin  and  kreatinin  reduce  the 
alkaline  picric  solution  by  the  aid  of  heat.  As  the  daily  secretion  of 
kreatinin  in  the  urine  is  11.5  grains,  according  to  Thudicum,  and  9  to 
20  grains  according  to  Neubauer,  it  is  not  at  all  unlikely  that  the  reaction 
found  by  Dr.  Johnson  between  normal  urine  and  picric  acid  may  be  due 
to  this  substance. 

Dr.  Oliver's  test  for  sugar  is  the  intensely  blue,  indigo  carmine,  or  the 
sulph-indigotate  of  sodium,  in  the  shape  of  a  test-paper,  since  the  test  is 
not  available  in  the  aqueous  form. 

The  effect  of  glucose  upon  the  indigo-carmine  is,  in  the  presence  of  heat, 
to  decolorize  it,  producing  in  the  course  of  such  decolorization  a  charac- 
teristic play  of  colors,  which  may  even  be  availed  of  for  the  quantitative 
estimation  of  sugar.  One,  or  at  most  two  drops  of  diabetic  urine  intro- 
duced into  a  solution  made  by  covering  one  of  the  test-papers  with  water, 
and  gently  heating  it,  will  cause,  within  a  minute  after  the  first  simmer, 
a  beautiful  violet  tint  to  spread  throughout  the  bright-blue  solution  ;  very 
quickly,  the  violet  deepens  and  passes  into  purple  ;  this,  in  its  turn,  melts 
into  reddish-purple,  which  gives  place  to  various  tints  of  red,  orange, 
and  finally  a  straw-color,  which  remains  without  further  change  how- 
ever long  the  fluid  is  heated.  Now,  on  shaking  the  tube,  the  colors  return 
in  the  inverse  order  to  that  in  which  they  appeared,  a  result  which  is  due 
to  the  reoxidation  of  the  indigo. 

The  reaction  is  truly  a  beautiful  one,  but  for  further  details  we  must 
refer  the  reader  to  Dr.  Oliver's  little  book,  adding  here  that  the  test- 
papers,  both  for  albumen  and  sugar  testing,  may  now  be  obtained  in 
this  country,  of  Parke,  Davis  &  Co.,  neatly  packed  in  a  box  along  with  a 
graduated  test-tube  and  dropping-tube,  and  directions  for  their  use. 

Dr.  Oliver  has  carefully  compared  this  test  with  Fehling's,  which  he 
regards  as  the  best  glucose  test,  with  results  indicating  equal  delicacy. 
Further,  he  has  compared  the  behavior  of  the  indigo-carmine,  the  cupric 
and  picric  tests,  when  boiled  in  the  presence  of  various  substances.  These 
are  his  results  : — 

Of  the  constituents  of  normal  urine  found  as  giving  no  reaction  with 
indigo-carmine  or  Fehling,  are  urea,  kreatin,  kreatinin,  urates,  chlorides, 
phosphates,  unoxidized  sulphur,  hippuric  acid,  sulphates,  lactates,  oxa- 
lates, ammonia,  butyric  acid.  Of  these,  kreatin  and  kreatinin  reduced  the 
alkaline  picric  solution.    Indigo-carmine  remained  unchanged,  but  Fehling 


218 


Reviews. 


[Jan. 


was  reduced  by  uric  acid,  oxalic  acid,  and  lactic  acid.  Of  constituents 
of  abnormal  urines,  leucine,  tyrosin,  albumen,  peptones,  non-saccharine 
bile,  blood,  pus,  and  mucus  gave  no  reaction  with  indigo-carmine  or 
Fehling.  Indigo-carmine,  Fehling,  and  picric  acid  were  all  reduced  by 
ammonium  sulphide.  Indigo-carmine  and  picric  acid  were  reduced  by 
inosite,  and  Fehling  was  turned  olive-green  by  it.  Of  other  substances, 
cane-sugar,  pure  glycerine,  mannate,  boiled  starch,  gum  acacia,  glycyr- 
rhizin,  and  salicin  produce  no  reaction  with  indigo  carmine  or  Fehling, 
while  gum  acacia  reduces  picric  acid,  and  milk-sugar  and  dextrin  reduce 
all  three.  Of  medicinal  substances  quinine,  morphia,  codeia,  atropin, 
caffeine,  santonin,  strychnine,  balsam  of  copaiba,  benzoate  of  lithia,  hypo- 
phosphates,  iodides,  liquor  pepticus,  ether,  and  arbutin,  exhibit  no  re- 
action with  indigo-carmine  and  Fehling.  Iron  sulphate,  gallic  and  tannic 
acids  reduce  all  three  reagents.  Indigo  is  unaffected  while  Fehling  is 
reduced  by  chloroform,  resin,  carbolic  acid,  sodium  salicylate,  jalapin,  and 
chloral.  The  urine  of  persons  taking  chloral  hydrate  reduces  Fehling' '$ 
solution,  the  bismuth  test,  and  salts  of  silver.  In  summary,  out  of  64 
substances  experimented  with,  Fehling  was  reduced  by  15,  picric  acid 
by  11,  and  indigo-carmine  by  8. 

The  quantitative  testing  by  the  indigo  papers  is  only  claimed  by  Dr. 
Oliver  to  be  approximate.  To  us  it  seems  troublesome,  but  so  much  de- 
pends in  these  matters  upon  habit  and  personal  experience,  that  it  is  not  fair 
to  judge  from  such  a  limited  opportunity  as  our  own.  To  the  practitioner, 
any  test  requiring  apparatus  even  slightly  specialized,  is  apt  to  be  dis- 
carded for  that  which  requires  only  simple  tubes.  We  hold  that  for  sugar 
some  kind  of  quantitative  testing  is  absolutely  necessary,  and  the  simpler 
the  means  by  which  it  can  be  accomplished,  the  more  likely  are  those 
means  to  be  used.  With  Fehling's  solution  a  sufficiently  accurate  quan- 
titative estimation  of  sugar  maybe  made  with  the  test-tube  and  graduated 
measure,  or  even  graduated  test-tube  and  the  spirit  lamp.  Even  Dr. 
Johnson's  standard  fluid  and  apparatus,  simple  as  they  are,  are  in 
the  way  of  the  availability  of  the  picric  acid  for  quantitative  testing. 
Other  things  being  equal,  the  test  of  the  value  of  a  test  is  its  availa- 
bility. Each  of  the  three  tests  is  sufficiently  accurate  if  intelligently 
handled,  while  perhaps  the  Fehling's  solution  requires  most  skill  in  its 
use  for  small  quantities  of  sugar,  and  we  await  with  interest  the  result  of 
a  year's  experience  of  the  profession  with  them,  after  they  have  become 
sufficiently  known.  J.  T. 


Art.  XXV — The  Diagnosis  of  Diseases  of  the  Spinal  Cord.  By  W.  R. 
Gowers,  M.D.,  F.R.C.P.,  Assistant  Professor  of  Clinical  Medicine  in 
University  College,  Physician  to  University  College  Hospital,  and  to 
the  National  Hospital  for  Paralyzed  and  Epileptics.  Third  edition,  pp. 
92.    Philadelphia:  P.  Blakiston,  Son  &  Co.,  1884. 

The  admirable  manual  of  Dr.  Gowers,  issued  in  1879,  has  done  much  to 
stimulate  the  intelligent  study  of  diseases  of  the  cord,  and  that  such  a  guide 
was  really  wanted  is  shown  by  the  exhaustion  of  two  large  editions  within 
four  years.  The  only  important  change  in  this  edition  is  a  new  section 
on  the  diagnosis  of  functional  from  organic  lesions  of  the  cord,  to  which 


1885.]       Stille,  Maisch,  The  National  Dispensatory.  219 


we  will  briefly  refer.  In  hysterical  paraplegia  there  is  no  disturbance  in 
the  central  functions  of  the  cord,  but  "there  is  loss  of  power  over  the  legs 
on  account  of  the  peculiar  ungeared  state  of  the  volitional  centres,  which 
is  at  the  root  of  all  true  hysteric  palsy."  The  various  objective  indica- 
tions of  spinal  trouble  are  absent ;  reflexes  and  sensation  are  normal ;  no 
muscular  wasting,  no  incontinence.  With  these  negative  features  there 
may  be  positive  indications  of  great  value  in  establishing  the  diagnosis,  as 
the  presence  of  unequivocal  symptoms  of  hysteria ;  the  mode  of  onset, 
emotional  shock  a  frequent  cause  ;  the  development  occupies  some  days, 
or  even  weeks ;  and,  thirdly,  the  character  of  the  weakness,  which  is  rarely 
absolute.  In  some  cases  there  are  indications  of  disturbance  of  the  func- 
tions of  the  cord  ;  spinal  tenderness,  increase  in  the  irritability  of  the 
muscles,  knee-jerk  excessive,  and  a  spurious  ankle  clonus  maybe  obtained. 
Owing  to  the  great  diagnostic  importance  of  the  true  ankle  clonus  it  is 
well  to  understand  the  character  of  the  voluntary  or  spurious  form,  which 
may  occur  in  hysterical  paraplegia.  In  the  typical  true  form  the  clonus 
begins  when  the  foot  is  first  pressed  up,  and  continues  so  long  as  the  pres- 
sure is  maintained  ;  but  in  the  voluntary  form  "  there  is  no  clonus  for  the 
first  few  seconds,  then  the  foot  and  the  observer's  hand  are  pressed  down 
by  a  voluntary  contraction  of  the  calf  muscles  which  is  broken  by  clonus." 
In  persistent  hysterical  contracture,  however,  there  may  be  a  regular  per- 
sistent clonus.  It  is  sometimes  a  difficult  matter  to  decide,  as  we  well 
remember  in  a  case  with  many  hysterical  aspects,  in  which  a  diagnosis  of 
organic  disease  was  made,  relying  on  the  existence  of  what  was  regarded 
as  a  true  ankle  clonus,  but  after  two  years'  spinal  trouble  complete  recovery 
corrected  the  diagnosis.  Where  there  is  rigidity  of  the  legs,  the  question 
as  to  whether  it  is  true  spasm  of  hysterical  contracture  is  still  more  difficult 
to  decide.  In  the  latter  the  spasm  is  greatest  at  the  extremity  of  the  limb 
and  is  constant,  but  can  be  overcome  by  steady  pressure,  and  the  clonus  is 
variable.  In  spastic  paraplegia  the  spasm  is  equal  throughout  the  limb, 
variable  in  intensity,  almost  exclusively  extensor,  and  the  clonus  is  uni- 
form. W.  O. 


Art.  XXVI  The  National  Dispensatory:    Containing  the  Natural 

History,  Chemistry,  Pharmacy,  Actions  and  Uses  of  Medicines,  includ- 
ing those  recognized  in  the  Pharmacopoeias  of  the  United  States,  Great 
Britain,  and  Germany,  with  numerous  references  to  the  French  Codex. 
By  Alfred  Stille,  M.D.,  LL.D.,  Professor  Emeritus  of  the  Theory 
and  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  University 
of  Pennsylvania  ;  and  John  M.  Maisch,  Phar.  D.,  Professor  of  Materia 
Medica  and  Botany  in  the  Philadelphia  College  of  Pharmacy.  Third 
edition,  thoroughly  revised,  with  numerous  additions.  With  three 
hundred  and  eleven  illustrations.  Royal  8 vo.  pp.  xvi.,  1755.  Phila- 
delphia: Henry  C.  Lea's  Son  &  Co.,  1884. 

The  National  Dispensatory  was  published  early  in  1879.  It  was  so 
well  received  that  a  third  edition  has  been  issued  in  a  little  more  than  five 
years  after  the  appearance  of  the  first.  This  fact  implies  that  the  quality 
of  the  work  is  highly  appreciated,  and  that  it  is  now  a  standard  of  refer- 
ence well  established  in  the  opinion  of  the  medical  public,  a  position  which 
its  merit  entitles  it  to  hold. 


220 


Reviews. 


[Jan. 


Compared  with  the  first,  this  edition  is  much  improved,  and  is  enlarged 
by  127  pages.  The  length  of  the  page  is  increased  by  six  lines,  and  the 
lines  are  more  than  a  half  an  inch  longer,  so  that  the  volume  contains 
much  more  matter,  probably  equivalent  to  the  contents  of  at  least  200 
pages  of  the  first  edition  ;  and  110  illustrations  have  been  added. 

The  theme  of  exegesis  here  is  chiefly  the  Pharmacopoeia  of  the  United 
States,  with  the  British,  German,  and  French  Pharmacopoeias,  according 
to  the  latest  revisions.  To  justly  estimate  the  labor  bestowed  on  this 
work,  we  should  remember  that  a  pharmacopoeia  is  only  a  collection  of 
formulas  for  the  preparation  of  standard  compounds  selected  or  devised  by 
competent  persons  under  recognized  authority,  mainly  for  the  guidance  of 
apothecaries,  in  which  descriptions  of  constituent  materials  are  limited  to 
diagnostic  characteristics,  without  indication  of  dose  or  peculiar  virtue  of 
any  of  them  ;  and  that  a  dispensatory,  besides  the  gist  of  the  pharmacopoeias 
which  it  expounds,  embraces  names  and  synonyms,  origin,  chemical  and 
commercial  history,  physical  properties,  methods  of  preparation  and  ad- 
ministration, pharmaceutical  uses,  effects  on  living  organisms,  doses  and 
clinical  application  of  every  medicine  or  compound  named  in  the  pharma- 
copoeias, and  also  of  every  article,  though  not  recognized  in  them,  that  is 
employed  in  the  treatment  of  disease.  A  dispensatory  is,  in  fact,  a  full 
summary  of  materia  medica,  pharmacy,  and  therapeutics,  a  repertory  of 
knowledge  in  the  premises,  to  which  physicians  and  apothecaries  may  con- 
fidently refer. 

The  varied  and  extensive  attainments,  coupled  with  painstaking  in- 
dustry and  habitual  accuracy  of  statement,  necessary  to  produce  such  a 
book,  are  very  rare.  In  the  volume  before  us,  there  is  abundant  evidence 
that  the  authors  of  the  National  Dispensatory  possess  all  the  requisite 
qualifications  for  the  work,  and  that  they  have  used  them  without  stint 
and  with  eminent  success.  Seemingly,  all  English,  German,  and  French 
authorities  in  materia  medica,  pharmacy,  and  therapeutics,  the  most  recent 
publications  and  reports,  have  been  consulted,  considered,  and  judiciously 
referred  to,  so  that  we  have  presented  to  us  in  the  account  of  every  article 
named  a  summary  of  what  is  known  or  supposed  to  be  known  about  it  at 
the  date  of  publication. 

Without  any  reason  which  is  now  conclusive  or  apparent,  the  satisfac- 
tory method  of  expressing  the  quantities  of  materials  embraced  in  the 
formulas  of  the  fifth  revision  of  the  Pharmacopoeia,  1870,  in  definite 
weights  and  measures,  was  abandoned,  and,  in  the  sixth  revision,  1880,  a 
mode  of  stating  quantities  in  "  parts  by  weight"  only,  was  adopted,  much 
to  the  dissatisfaction  of  a  vast  majority  of  those  who  have  occasion  to  make 
them  up.  To  obviate  the  inconvenience  arising  from  this  source,  to  facili- 
tate the  working  of  the  formulas  of  the  Pharmacopoeia  of  the  United  States 
of  1880  by  practical  physicians  and  pharmacists,  "parts  by  weight"  are 
translated,  in  the  National  Dispensatory,  into  definite  apothecaries'  weights 
and  measures,  stating  also  their  equivalents  in  the  terms  of  the  metric 
system,  but  only  proximately.  Measures  of  temperature  are  stated  accord- 
ing to  both  the  Fahrenheit  and  Centigrade  scales,  although  only  Fahren- 
heit's thermometer  is  in  common  use  in  the  United  States.  This  provision 
of  duplicate  terms  for  weights  and  measures  to  suit  different  tastes  some- 
what mars  simplicity  of  directions,  without  securing  any  apparent  practical 
advantage  :  it  merely  emphasizes  an  opinion  that  expressing  quantities  in 
"  parts  by  weight,"  and  recognizing  the  metric  system  at  this  time  in  the 
Pharmacopoeia  of  the  United  States,  is  premature. 

Some  optimists  may  believe  that  all  nations  should  speak  only  one  and 


1885.]      Corre,  A  Treatise  on  the  Fevers  of  Hot  Climates. 


221 


the  same  language,  make  coins  of  the  same  name  and  value,  and,  as  a 
first  step  towards  the  wished-for  state,  that  only  one  unit  of  measure,  of 
weight,  and  of  temperature  should  be  lawfully  employed  by  all  peoples  alike ; 
but  it  will  be  yet  very  long,  nevertheless,  before  practical  men  of  the  Anglo- 
Saxon  family — the  bread-winners — who  employ  weights  and  measures  in 
their  many  daily  vocations,  as  land-surveyors,  constructors  of  buildings  and 
ships,  machinists,  mechanics,  traders — will  be  convinced  of  the  necessity, 
or  propriety  even,  of  adopting  the  Centigrade  thermometer  and  the  metric 
system  of  weights  and  measures  exclusively,  seeing  that  the  metric  system 
rests,  in  fact,  on  an  arbitrary  basis,  and  is  not  more  exact  or  convenient 
than  any  other.  Comparatively  few  Americans  are  in  favor  of  it.  It  is 
conjectured  that  probably  less  than  ten  per  cent,  of  all  the  physicians  and 
apothecaries  in  active  professional  business,  including  those  among  us  of 
foreign  birth,  or  parentage,  look  forward  to  the  introduction  of  the  use  of 
the  metric  system  in  prescribing,  and  into  the  pharmacist's  laboratory,  as 
an  improvement  fraught  with  palpable  benefit  in  any  sense  to  either  practi- 
tioner or  patient.  The  question  whether  the  entire  system,  standards,  and 
names  of  the  weights  and  measures  in  lawful  use  by  fifty  millions  of  people 
shall  be  totally  changed  without  lawful  authority,  is  profoundly  important. 
It  is  made  very  complex  by  the  multitude  of  interests  concerned,  and, 
therefore,  its  solution  should  be  confided  to  our  wisest  statesmen  in 
authority.  Until  after  the  national  legislature  has  determined  that 
the  people  shall  use  the  metric  system,  its  adoption  by  any  profession  or 
class  seems  untimely,  although  statutes  of  the  United  States  permit  its 
use  at  this  time.  If  the  Pharmacopoeia  of  the  United  States  of  America 
were  prepared  and  published  under  the  direct  authority  of  the  government, 
and  it  is  hoped  the  next  revision  will  be,  it  is  probable  that  quantities 
would  be  expressed  in  it  only  in  the  lawfully  prescribed  weights  and 
measures  in  common  use,  and  in  this  respect  not  in  advance  of  the  times. 

The  appendix  of  the  National  Dispensatory  contains  a  table  of  maxi- 
mum doses  ;  tables  of  different  weights  and  measures;  rules  for  converting 
apothecaries'  weights  and  measures  into  their  respective  equivalents  into 
metric  terms  ;  a  table  relating  to  specific  gravities  of  liquids  ;  a  table  for 
comparing  degrees  of  the  Centigrade  and  Fahrenheit  thermometers ;  a  table 
of  elements,  and  a  list  of  reagents. 

A  general  index,  in  three  columns,  occupies  66  pages,  and  an  index  of 
therapeutics,  34  pages. 

In  every  respect,  the  work,  in  all  its  parts,  is  well  done,  and  creditable 
to  both  authors  and  publishers.    Their  enterprise  deserves  success. 

W.  S.  W.  R. 


Art.  XXVII  Traite  desFievres  Bilieuses  et  Typhiques  des  Pays  Ohauds. 

Par  le  Dr.  A.  Corre,  Medecin  de  Ire  Classe  de  la  Marine ;  Pro- 
fesseur  Agrege  a  l'Ecole  de  Medecine  Navale  de  Brest.  Avec  35 
Traces  de  Temperature  dans  le  text.  8vo.  pp.  567.  Paris  :  Octave 
Doin,  1883. 

A  Treatise  on  the  Fevers  of  Hot  Climates.    By  Dr.  A.  Corre. 

This  elaborate  and  learned  treatise,  written  from  the  standpoint  of  the 
naval  surgeon,  and  devoted  to  the  consideration  of  a  group  of  diseases 
peculiar  to  or  greatly  modified  by  their  occurrence  in  tropical  and  sub- 


222 


Reviews. 


[Jan. 


tropical  lands,  will  scarcely  come  into  the  hands  of  many  of  the  readers  of 
this  journal.  Nevertheless  to  a  discriminating  few,  whose  lot  is  cast  in 
such  lands,  it  will  be  in  some  respects  very  welcome  and  useful.  It  will 
find  place  also  upon  the  shelves  of  physicians  who  are  interested  in  the 
study  of  the  general  subject  of  the  fevers. 

Dr.  Corre  in  the  preface  briefly  informs  his  readers  how  he  was  led  to 
write  this  book.  Unable  to  accept  the  description  of  certain  pyretic 
diseases,  as  they  stand  in  the  classic  works  on  medicine,  he  has  under- 
taken to  recast  the  whole  subject  of  these  bilious  and  typh-fevers  (Jievres 
bilieuses  et  typhiques)  as  they  are  observed  in  hot  countries.  His 
reason  for  this  undertaking  is  that  the  systematic  accounts  are  so  incom- 
plete and  misleading,  and  the  differential  diagnosis  so  obscure,  that  these 
diseases  have  been  declared  to  constitute  the  chaos  of  inter-tropical 
pathology.  He  has  not  been  unaware  of  the  difficulties  of  this  task,  nor 
does  he  pretend  to  have  solved  a  problem  which  is  worthy  of  the  con- 
verging labors  of  more  than  one  generation  of  students.  But  he  has 
striven  to  render  the  labors  of  those  who  follow  him  in  the  investigation 
of  exotic  fevers  easier  and  freer  from  obstacles. 

The  preface  concludes  as  follows  : — 

"  Nous  avons  observe  et  nous  avons  apprecie  les  faits  avec  conscience  et 
independance  :  nous  souhaitons  que  nos  lecteurs  jugent  notre  oeuvre  avec 
l'esprit  qui  nous  l'a  dietee." 

One  may  truly  write  an  excellent  book  and  make  shipwreck  of  a  page  of 
preface. 

A  general  study  of  fevers  very  properly  leads  the  way  to  the  considera- 
tion of  the  special  fevers,  which  are  taken  up  in  the  following  order  : — 

I.  (a)  Common  bilious  fever  or  gastro-bilious  fever  (Fievre  bilieuse 
banale,  ou  gastrique  bilieuse). 

(b)  Ardent  or  inflammatory  endemic  fever  (Fievre  dite  bilieuse  in- 
flammatoire.) 

II.  Remittent  fever  (Fievre  bilieuse  paludeenne). 

III.  Bilious  remittent  with  hematuria,  haemorhagie  malarial  fever 
(Fievre  bilieuse  hematurique  ou  melanurique  hemoglobinurique). 

IV.  Typho-malarial  fevers  (Fievres  typho-malarieuses). 

The  author  understands  by  typho-malarial  fevers,  pyrexias  which, 
engendered  under  the  double  influence  of  malarial  conditions  and  typh 
conditions  (conditions  typhiques),  present  an  association  of  phenomena 
suggesting  both  sources  of  intoxication. 

There  are  three  forms  : — 

1.  Fevers  that  are  typho-malarial  by  association  or  duplication.  Here 
there  is  a  parallel  and  simultaneous  evolution  of  two  pyrexias,  each 
developed  under  the  influence  of  its  own  infection,  independently  of  its 
congener. 

2.  Fevers  that  are  properly  called  typho-malarial.  Here  the  pyrexia  is 
simple,  engendered  under  the  influence  of  a  single  agent  (typho-malaria) 
originating  externally  to  the  organism  infected.  These  fevers  may  be 
designated  clinically  by  the  term  Jievres  malarieuses  typhoidiform. 

3.  Transformed  typho-malarial  fevers,  in  which  the  malarial  fever  be- 
comes typhoid  (typhique),  under  the  influence  of  an  infection  engendered 
by  the  organism  itself.  This  form  is  called ^evre  malarieuse  typhoid  par 
transformation. 

This  subject,  and  much  that  follows  it,  are  rendered  obscure  by  the  re- 
tention of  the  old  view  as  to  the  common  etiological  relations  of  the  group 


1885.]      Corre,  A  Treatise  on  the  Fevers  of  Hot  Climates.  223 


of  fevers  to  which  the  term  typhus.w&s  formerly,  and  is  still  by  Continental 
writers  comprehensively  applied ;  and  of  which  typhus  recurrens  (relapsing), 
typhus  exanthematicus  (typhus),  typhus  abdominalis  (enteric),  typhus 
amaril  (yellow  fever),  and  typhus  cerebro-spinal  (cerebro-spinal  fever)  are 
looked  upon  as  varieties. 

Great  indeed  must  be  the  state  of  confusion  in  which  this  subject  of  the 
fevers  exists  in  the  classical  treatises,  if  the  nosological  arrangement  of 
the  author  is  an  improvement  upon  it.  Compared  with  the  simple  plan 
of  English  and  American  pathologists,  which  refers  particular  fevers  to 
single  and  distinct  (specific)  causes,  it  is  indeed,  "a  chaos  of  pathology." 
Dark  indeed  must  be  the  border  land  of  differential  diagnosis,  if  this 
arrangement  can  illumine  its  obscurity. 

V.  Relapsing  fever.  (Typhus  recurrent  et  fievre  typhoide-bilieuse — 
typhus  collapsive.) 

This  /ever  is  defined  as  an  epidemic  fever  observed  under  an  especial 
medical  constitution  (line  constitution  medic  ale  parti culih'e),  to  which 
miasmatic  influences  appear  to  be  not  always  foreign,  and  under  condi- 
tions which  ordinarily  give  rise  to  typhus  exanthematicus ;  a  fever  charac- 
terized by  special  phenomena  of  a  typh  (typhique)  character,  often  ac- 
companied by  the  bilious  state,  by  tendency  to  adynamia,  by  relapses 
under  the  form  of  recurrence  at  long  intervals,  by  the  habitual  presence 
of  a  spirillum  in  the  blood,  by  the  frequency  of  enlargement  and  softening 
of  the  spleen.  Relapsing  fever  is  described  and  classed  with  the  "bilious- 
typhoid"  of  Greisinger  and  other  writers  as  one,  the  latter  being  the 
specialized  form  that  occurs  in  tropical  climates. 

VI.  Yellow  fever  (Typhus  amaril,  ou  fievre  jaune), 

VII.  Enteric  or  typhoid  fever  (Typhus  abdominal,  ou  fievre  typhoide, 
and  in  the  same  chapter  and  under  the  same  general  heading), 

VIII.  Typhus  fever  (Typhus  exanthematique),  and, 

IX.  A  form  of  typhus  peculiar  to  the  high  inter-tropical  plateaus  (Typhus 
des  hauts  plateaux  des  regions  inter-tropical). 

This  last  fever  has  been  observed  among  the  peoples  dwelling  in  the 
high  regions  of  Peru  and  Mexico.  It  has  been  variously  looked  upon, 
sometimes  as  enteric,  sometimes  as  typhus  fever,  but  the  author,  whose 
efforts  to  observe  facts  with  conscience  and  independence  (avec  conscience 
et  independance)  have  been  clogged  by  the  very  traditions  from  which  he 
seeks  to  escape,  agrees  with  Jourdanet,  in  regarding  this  fever  as  due  to  an 
original  form  of  typh-activity  (typhism),  whatever  that  may  be.  This 
opinion  is  shown  to  be  untenable  by  the  evidence  adduced  to  prove  it, 
namely,  the  symptomatology  and  pathological  anatomy  of  the  disease, 
which  are  clearly  those  of  enteric  fever,  modified,  perhaps,  by  the  high 
altitude,  perhaps  by  the  soil,  or  by  both,  in  which  it  exists. 

This  book  is  written  in  a  style  learned  without  pedantry,  exact  without 
undue  minuteness  of  statement,  graphic  and  simple ;  its  descriptions  are 
brief,  terse,  and  accurate  ;  its  sincerity  manifest,  its  erudition  profound. 
Yet  its  author  has  been  so  hampered  by  doctrines  no  longer  tenable,  and 
in  truth  so  little  recognized  as  to  be  almost  unknown  to  English  students 
of  our  day,  that  to  place  it  in  the  hands  of  our  medical  students  would 
result  in  a  bewilderment  that  would  indeed  amount  to  a  "  pathological 
chaos"  come  again.  J.  C.  W. 


224 


Reviews. 


[Jan. 


Art.  XXVIII  On  the  Pathology  and  Treatment  of  Gonorrhoea.  By 

J.  L.  Milton,  Senior  Surgeon  to  St.  John's  Hospital  for  Diseases  of 
the  Skin,  London.  Fifth  edition.  8vo.  pp.  viii.,  306.  New  York  : 
William  Wood  &  Co.,  1884. 

Max  is  everywhere  a  combative  animal,  and  no  ethnological  line  can 
be  drawn,  on  one  side  of  which  it  may  be  said  men  do,  and  on  the  other 
side  men  do  not,  love  to  see  a  fight.  And  it  is  especially  true  that  men 
love  to  see  a  single  man  holding  his  own  against  a  number  of  opponents. 
To  such  a  spectacle  this  book  of  Mr.  Milton's  invites  the  reader.  From 
beginning  to  end  it  is  controversial,  and  this  apparently  not  from  choice, 
but  from  necessity.  In  the  preface  the  author  testifies  his  appreciation  of 
the  criticism  his  attitude  to  others  will  provoke.  "  It  is  not  to  be  ex- 
pected," he  says,  "  that  the  adverse  judgment  passed  upon  mai^  reme- 
dies, which  have  been  at  one  time  or  other  so  strongly  advocated,  will 
prove  acceptable  to  those  who  recommended  them  to  public  favor.  But 
for  this  there  is  no  help.  Experience  compels  me  to  say  that  they  have 
not  fulfilled  the  expectations  which  the  first  accounts  of  them  were  calcu- 
lated to  raise."  In  the  context  the  promise  with  which  this  sentence  is 
big  is  abundantly  fulfilled. 

Mr.  Milton  begins  with  a  study  of  the  antiquity  of  gonorrhoea,  in  which 
he  not  only  attempts  to  refute  the  arguments  of  those  who  find  evidence 
of  its  existence  since  the  earliest  times  of  human  history,  but  also  ridicules 
some  of  their  evidence  unstintedly.  It  maybe  because  of  a  bias  in  favor  of  his 
views  that  we  enjoy  Mr.  Milton's  statement  of  them,  and  think  it  very  well 
done.  As  he  cites  one  after  another  of  the  writings  upon  which  the  opinion 
that  their  authors  were  familiar  with  gonorrhoea  rests,  we  not  only  admire 
his  thoroughness,  but  sympathize  with  the  righteous  indignation  he  seems 
to  feel  that  such  broad  claims  should  rest  on  such  slim  pretensions.  Simi- 
larly, when  he  treats  of  the  relation  of  acrid  vaginal  discharges  to  the 
production  of  a  running  disease  of  the  urethra,  we  are  moved  with  admi- 
ration, although  here  it  may  be  another  prejudice  which  prevents  our 
thinking  his  reasoning  quite  so  conclusive  as  we  found  it  before.  And 
yet,  one  very  firmly  wedded  to  the  belief  that  gonorrhoea  is  simply  a  ure- 
thritis, and  not  of  a  specific  nature — wre  do  not  mean  syphilitic,  of 
course — may  well  ponder  the  arguments  with  which  Mr.  Milton  supports 
the  opinion  that  it  is  a  specific  urethritis.  He  may  be  right,  notwithstand- 
ing the  fact  that  he  is  almost  alone  in  his  present  opinions. 

One  of  the  most  interesting  parts  of  this  book  treats  of  the  results  of 
gonorrhoea.  Here  he  occupies  a  few  pages  in  annihilating,  quoad  hoc, 
Dr.  Noeggerath,  of  New  York,  and  his  applauder,  Dr.  Angus  McDonald, 
of  Edinburgh.  The  former  has  given  accounts  of  the  effects  of  this  dis- 
ease, which,  Mr.  Milton  says,  "are  enough  to  make  one's  hair  stand  on 
end."  These  accounts,  the  reader  will  probably  know,  included  a  degree 
of  impotence  on  the  part  of  men  and  of  sterility  on  the  part  of  women 
which,  as  it  is  easy  to  calculate,  would  in  a  short  time  depopulate  any 
country.  Of  course,  they  were  erroneous  ;  and  one  wonders  how  Dr. 
Noeggerath  ever  came  to  put  them  before  a  world  which  has  some  expe- 
rience of  its  own  to  guide  it,  and  some  ability  to  see  the  absurdity  of  the 
legitimate  conclusion  of  such  exaggerations. 

To  the  views  of  others,  which  he  cannot  indorse,  Mr.  Milton  opposes 
himself,  not  only  when  he  has  some  positive  opinion  of  his  own  to  otfer, 


1885.]      Milton,  Pathology  and  Treatment  of  Gonorrhoea. 


225 


but  also  when  he  has  to  confess  that  he  is  stumbling  blindfold  through  a 
conjecture  ;  for  he  holds  truly,  that  it  is  doubtful  if  ever  an  erroneous 
hypothesis  assisted  in  the  discovery  of  a  truth  which  men  would  not  have 
found  out  equally  well  without  it. 

But,  interesting  as  the  more  theoretical  parts  of  the  book  before  us  must 
prove  to  every  reader,  it  is  likely  that  the  majority  will  care  most  for 
what  the  author  says  as  to  the  treatment  of  gonorrhoea.  Here  his  large 
experience  adds  great  weight  to  whatever  he  says.  Here,  again,  however, 
he  is  to  be  found  in  the  habitual  attitude  of  a  sole,  brave  contestant.  But 
it  is  fine  !  He  turns  to  every  side,  both  attacking  and  repelling  attack. 
His  sweeping  ridicule  spares  no  one  whom  it  can  be  made  to  reach.  Again 
and  again  it  cuts  down  those  who  have  claimed  so  much  for  certain 
methods  as  to  make  them  fair  objects  of  criticism.  "  There  may  be  too  much 
of  a  good  thing,"  he  says  once,  "and  I  think  we  have  had  too  much  in 
the  shape  of  novelties  for  many  years  past ;  merely  adding  to  the  list  of 
remedies,  already  long  enough,  many  of  which  are  just  as  useful  as  a  beane 
putte  into  ye  harte  of  a  black  cat,  and  can  do  no  good  whatever."  His  ownn 
reflections  upon  the  present  state  of  the  therapeusis  of  gonorrhoea  lead  him 
to  the  statement  that  it  is  in  inextricable  confusion.  Besides  suggestions 
which  he  rejects  with  little  ceremony  he  takes  up  and  considers  in  detail 
the  merits  of  a  number  of  more  or  less  commonly  employed  plans.  After 
all,  he  comes  back  to  the  use  of  injections  and  the  local  application  of  heat 
to  the  penis,  in  his  well-known  way.  For  injections  he  makes  a  strong 
plea,  and  defends  them  against  the  imputation  that  they  cause  stricture 
and  orchitis.  But  he  makes  it  clear  that  he  speaks  as  to  wise  men,  and 
cannot  be  held  responsible  for  the  consequences  of  fool-hardiness  or  care- 
lessness. 

The  attempt  to  abort  an  attack  of  gonorrhoea  Mr.  Milton  thinks  justifi- 
able :  1.  When  patients  present  themselves  before  great  pain  and  running 
have  set  in.  2.  In  cases  when  the  patients  have  had  gonorrhoea  before, 
and  the  present  attack  does  not  appear  to  be  very  severe.  3.  Where  the 
patient  is  desirous  of  an  immediate  cure  at  any  price.  To  secure 'the 
object  desired  the  patient  must  make  water,  and  then  receive  an  injection, 
at  the  hands  of  the  surgeon,  of  a  solution  of  nitrate  of  silver,  five  grains  to 
the  ounce  of  distilled  water.  This  injection  should  be  retained  for  several 
minutes.  If  great  pain  ensues  it  is  to  be  treated  by  bathing  the  penis 
with  hot  water ;  and  a  hot  bath  will  generally  remove  any  pain  which 
resists  the  local  application.  After  the  injection  four  or  five  grains  of 
calomel  are  to  be  given,  followed  by  a  saline,  or  mixed  saline  and  vege- 
table, purge  every  two  hours  till  the  bowels  have  been  well  scoured  out  by 
several  loose  stools.  The  diet  is  also  to  be  restricted,  and  light.  After 
each  stool  the  patient  is  to  use  an  injection  of  the  sulphate  of  zinc,  three 
to  five  grains  to  the  ounce.  This  plan  persevered  in  for  a  day  or  two  will 
effect  a  cure  by  that  time,  or  it  will  be  clear  that  the  case  is  not  amenable 
to  this  sort  of  treatment.  In  the  latter  case  Mr.  Milton  advises  the  use  of 
mild  diuretics  and  aperients. 

As  an  outcome  of  his  experimentation  in  regard  to  formulas  for  the  ordi- 
nary treatment  of  gonorrhoea,  Mr.  Milton  gives  the  following  prescriptions  : 

1.  R  Potassae  chloratis,  5ij  ;  aquae  bullientis,  fgiv. — M.  et  agita  bene, 

donee  solutio  fit,  dein  adde  potassae  acetatis,  5lj  >   spir.  juniperi,  f^ss  ; 

mist,  camphorae  q.  s.  ad  f^vj  Misce.    Sig.  Coch.  ampl.  duo  bis  quo- 

tidie  sumenda.     2.  R  Pil.  colocynth.  comp.,  5SS  5  hydrargyri,  £)ss  ; 

ext.  hyoscyami,  9j — M.  Ft.  pil.  xij.  Sig.  Sumat  j  vel  ij  hora  decubitura. 
No.  CLXXVII.—Jan.  1885.  15 


226 


Reviews. 


[Jan. 


In  the  curative  power  of  these  two  prescriptions  Mr.  Milton  has  great 
faith.  But  a  number  of  cases  require  the  additional  use  of  injections. 
The  best  salt  for  this  purpose  is  the  nitrate  of  silver,  to  be  injected  by  the 
surgeon,  in  a  strength  of  half  a  grain  to  the  ounce  of  water  at  first,  and 
gradually  rising  to  that  of  from  two  to  ten  grains  in  accordance  with  the 
patient's  tolerance  of  it.  The  patient  must  also  use  at  home  an  injection 
containing  one  or  two  grains  of  the  sulphate  of  zinc  and  a  quarter  or  half 
a  grain  of  the  chloride  of  zinc  to  the  ounce  of  water.  This  injection,  like 
the  preceding,  is  to  be  increased  in  strength  as  the  case  goes  along,  being 
always  strong  enough  to  produce  a  slight  sense  of  heat  for  ten  or  fifteen 
minutes.  Mr.  Milton  advises  the  use  of  a  syringe  with  a  nozzle  at  least  an 
inch  and  a  half  long.  This  is  best  made  of  silver,  drawn  solid,  while  the 
barrel  is  of  glass.  In  regard  to  the  results  of  treatment  in  this  way  Mr. 
Milton  remarks  that  he  cannot  satisfy  himself  as  to  the  average  time  the 
cases  require.  "  A  great  many  get  well,"  he  says,  "  in  from  four  to  four- 
teen days  ;"  but  he  has  seen  cases  that  made  little  apparent  improvement 
in  as  much  as  four,  and  even  eight  weeks. 

The  part  of  this  book  which  follows  is  occupied  with  a  consideration  of 
the  complications  of  gonorrhoea,  and  with  its  great  sequela,  gleet ;  but  on 
this  we  have  not  time  to  dwell. 

On  the  whole,  we  regard  this  as  a  very  interesting  and  instructive  book. 
It  is  the  fruit  of  a  ripe  experience,  and  with  all  its  opposition  to  the 
opinions  and  assertions  of  others,  it  does  not  fall  into  rudeness,  and,  indeed, 
preserves  a  remarkable  restraint  in  view  of  the  comparatively  lonely 
position  occupied  by  the  author,  to  which  we  have  referred,  and  which  he 
evidently  feels.  We  cannot  but  think  he  sometimes  hits  harder  than  is 
necessary  ;  but  no  more  can  we  escape  the  conviction  that  he  feels  that  he 
is  coming  to  the  rescue  of  the  truth,  and  that  the  truth  is  being  smothered 
under  a  mass  of  false  appearances  and  false  logic.  To  expose  the  real 
nature  of  these,  as  he  intends  to  do,  is  a  work  deserving  sympathy  and 
cooperation  from  all  men.  The  author  may  not  be  altogether  right,  nor 
those  who  differ  from  him  altogether  wrong ;  but  in  his  motives  he  is 
undoubtedly  right,  and  no  one  who  is  moved  by  like  motives  can  blame 
him  much  for  a  zeal  which  speaks  plainly  in  so  good  a  cause.     C.  W.  D. 


Art.  XXIX  Recherches  cliniques  et  therapeutiques  sur  V  Epilepsie, 

I'Bysterie  et  ridiotie,  compte  rendu  du  service  des  'epileptiques  et  des 
enjants  idiots  et  arrieres  de  Bicetre  pendant  Vannee  1881,  par  Bour- 
neville,  Medecin  de  Bicetre.  Bonnaire  (E.)  et  Wuillamie,  internes  du 
service.    Paris  :  Aux  Bureaux  du  Progres  Medical,  1882. 

Recherches  cliniques  et  therapeutiques  sur  V Epilepsie,  V  Hysterie  et 
VIdiotie,  et  arr Teres  pendant  Vannee  1883,  par  Bourneville,  Medecin 
de  Bicetre.  Bonnaire,  Bontier  Leflaive,  internes  du  service ;  P. 
Brecin  et  Seglas,  Docteurs  en  Medecine.  Volume  iv.,  avec  8  figures  et 
deux  planches.    Paris  :  Aux  Bureaux  du  Progres  Medical,  1884. 

These  two  volumes  contain  a  large  amount  of  valuable  clinical  and 
pathological  work  which  the  authors  have  been  able  to  do  in  connection 
with  the  service  for  epileptics  and  idiots  at  the  Bicetre.  As  we  learn  by 
the  introductory  statistical  section  the  number  of  inmates  on  December 


1885.]     Recherches  cliniques  et  therapeutiques  sur  l'Epilepsie.  227 


31,  1881,  was  297,  of  whom  71  were  idiots  or  imbeciles,  and  the  remainder 
epileptics,  adults  and  children,  and  of  sound  or  unsound  mind.  At  the 
same  time,  1883,  there  were  305  patients,  of  whom  only  19  were  idiots  or 
imbeciles,  and  the  greater  number  epileptics. 

The  clinical  report  for  1881  opens  with  an  account  of  three  cases  of 
idiocy  with  remarkable  cerebral  changes.  In  two  there  was  an  hypertro- 
phic sclerosis  of  certain  of  the  convolutions  due  to  a  local  proliferation  of 
the  connective  tissue  elements,  and  in  a  third  a  remarkable  condition  of 
meningoencephalitis  in  a  child  of  12  years  of  age.  Over  the  entire  right 
hemisphere,  with  the  exception  of  the  temporo-sphenoidal  lobe,  the  pia 
mater  and  the  gray  matter  were  so  closely  united  that  in  the  removal  the 
latter  came  away  from  the  white  substance  as  a  distinct  fold  or  shell. 
The  child  had  convulsions  for  six  years  and  left  hemiplegia.  Two  inte- 
resting cases  of  microcephaly  are  reported  at  length,  and  five  plates  illus- 
trate the  condition  of  the  brains,  which  weighed  only  640  and  650 
grammes.  The  details  of  the  structure  are  given  at  great  length,  and 
illustrate,  what  is  not  generally  recognized,  that  a  brain  maybe  very  small 
and  yet  the  convolutions  regular  and  proportionate.  Other  cases  of 
interest  are  :  rheumatic  arthropathies  in  an  ataxic,  epilepsy  with  exten- 
sive lesion  of  the  insula,  hystero-epilepsy  in  a  boy  treated  successfully  by 
the  cold  douche,  epilepsy  with  osteomalacia ;  and  lastly,  a  description  of 
an  outbreak  of  measles  among  the  children. 

The  volume  for  1883  contains  an  elaborate  article  of  86  pages  on  Mery- 
cism  or  Rumination  in  Man,  a  subject  in  which  French  writers  appear  to 
have  had  a  particular  interest.  After  a  preliminary  account  of  the  phy- 
siology of  the  act  in  ruminants  and  a  discussion  of  the  question  whether  in 
man  it  is  morbid  phenomenon  or  not,  the  whole  history  of  the  subject  is 
exhaustively  considered. 

Thirty-seven  cases  are  noted,  five  of  which  occurred  in  the  service  of 
the  Bicetre.  Of  these,  twenty-four  were  in  persons  of  sound  mind,  the 
remainder  in  idiots  or  the  insane.  The  act  must  be  distinguished  from 
vomiting  on  the  one  hand  and  simple  regurgitation  on  the  other.  It  is  a 
voluntary  effort  accomplished  largely  by  the  stomach  and  oesophagus,  and 
the  food  which  is  raised  is  subjected  to  a  second  mastication.  The  sensa- 
tions accompanying  the  act  are  often  pleasurable.  Imitation  sometimes 
plays  an  important  part  in  the  causation,  as  in  the  case  narrated  by  Koer- 
ner,  where  two  children  took  up  the  habit  from  an  hysterical  and  ruminat- 
ing governess.  Two  forms,  simple  and  dyspeptic,  described  by  Kcerner, 
are  recognized.  In  the  former  the  act  only  succeeds  a  very  full  meal, 
beginning  half  an  hour  after,  and  the  food  retains  its  proper  taste.  It  is 
only  at  the  end  of  the  act,  after  the  lapse  of  half  an  hour,  that  the  taste 
becomes  acid  and  unpleasant.  In  the  dyspeptic  form  the  act  may  begin 
almost  immediately  after  the  ingestion  of  even  a  small  quantity  of  food, 
and  the  taste  is  usually  acid  and  disagreeable.  Two  of  the  cases  at  the 
Bicetre  died  of  other  affections,  and  no  special  changes  were  observed  in  the 
stomach  or  oesophagus.  The  second  article  is  on  a  case  of  Hystero-epi- 
lepsy in  a  boy  cured  by  hydrotherapy  ;  the  third  on  chronic  meningo-ence- 
phalitis with  idiocy,  the  chronic  inflammation  in  this  case  being  more 
irregularly  distributed  over  the  hemispheres.  The  fourth  paper  is  upon 
a  case  of  idiocy  consecutive  to  hydrocephalus,  and  the  last  upon  idiocy 
from  simple  atrophy  of  the  brain. 

These  valuable  reports  afford  an  excellent  illustration  of  what  good 
work  can  be  done  when  the  clinical  and  pathological  material  of  an  institu- 
tion is  fully  utilized.  W.  0. 


228 


Reviews. 


[Jan. 


Art.  XXX  A  System  of  Human  Anatomy,  including  its  Medical 

and  Surgical  Relations.  By  Harrison  Allen,  M.D.,  Professor  of 
Physiology  in  the  University  of  Pennsylvania,  etc.  etc.  Section  V. 
Nervous  System.  Section  VI.  Organs  of  Sense,  of  Digestion,  and 
Genito-  Urinary  Organs.  4to.  pp.  xv.,  582-812.  Philadelphia:  Henry 
C.  Lea's  Son  &  Co.',  1883. 

"  Allen's  Anatomy"  is  now  published  in  full,  Sections  5  and  6  com- 
pleting the  work.  In  them  are  considered  the  nervous,  digestive,  respira- 
tory and  genito-urinary  systems,  together  with  sub-sections  on  topographi- 
cal anatomy,  on  malformations ,  and  on  the  method  of  making  post-mortem 
examinations.  If  anything  were  necessary  to  convince  us  that  there  has 
been  progress  made  in  anatomy  in  these  latter  years,  the  required  evi- 
dence might  easily  be  found  in  a  comparison  of  what  is  here  written  on 
the  spinal  cord  and  brain,  with  that  presented  in  the  text-books  and 
reference  volumes  of  twenty-five  years  ago.  More  than  fifty  pages  of 
Section  V.  are  occupied  with  the  macroscopical,  microscopical,  and  de- 
velopmental features  of  the  new  anatomy  of  the  central  organs ;  and  the 
value  of  such  anatomical  knowledge  is  shown  by  frequent  references  to 
reported  clinical  facts.  In  like  manner  in  the  consideration  of  the  cranial 
and  spinal  nerves,  while  origin,  course,  and  distribution  are  clearly  stated, 
cases  in  illustration  of  their  pathology  are  freely  introduced. 

The  Soemmering  classification  of  the  cranial  nerves  is  adopted.  The 
usual  exactness  of  anatomical  description  is  occasionally  interrupted  by 
statements,  the  errors  of  which  must  be  attributed  to  defective  proof-read- 
ing. For  example,  the  nucleus  of  origin  of  the  fourth  nerve  is  on  one 
page  placed  directly  in  front  of,  and  on  the  next  page  behind  that  of  the 
third ;  a  filament  joining  the  lingual  is  derived  from  the  mylo-hyoid 
muscle;  the  external  branch  of  the  spinal  accessory  is  stated  to  pass 
"obliquely  downward  and  outward  between  the  common  carotid  artery  and 
the  internal  jugular  vein"  ;  the  fourth  and  ophthalmic  branch  of  the 
fifth  are  given  as  entering  the  cavernous  sinus,  though  elsewhere  properly 
located  in  its  outer  wall.  The  Vidian  is  described  as  coming  from  the 
spheno-palatine  ganglion,  but  later  it  is  stated  that  the  present  belief  is 
that  it  passes  toward  the  ganglion.  Due  notice  is  taken  of  Bigelow's  and 
Sapolini's  views  of  the  origin  of  the  chorda  tympani. 

The  spinal  cord,  "  with  the  exception  of  the  terminal  filament,"  is  stated 
to  be  "  within  the  cervical  and  lumbar  portions  of  the  vertebral  canal." 
The  branches  of  the  brachial  plexus  are  classified  according  to  the  groups 
of  muscles  to  which  they  are  distributed ;  one  set  going  to  the  trunkal 
muscles,  a  second  to  the  extrinsic  muscles  of  the  upper  extremity,  and  a 
third  to  its  intrinsic  muscles.  Attention  is  called  to  the  fact  that  after 
division  of  the  tendon  of  the  biceps  femoris,  the  external  popliteal  nerve 
"  springs  up  so  as  to  occupy  its  place,  feeling  as  tense  as  the  tendon  did 
before  division.  The  inexperienced  operator  may  conclude  that  the  ten- 
don has  not  been  completely  divided,  and  under  these  circumstances  the 
knife  may  be  reintroduced,  and  the  nerve  divided."  The  middle  cardiac 
nerve  of  the  sympathetic  is  stated  "  to  run  downward  behind  the  internal 
carotid  artery,  and  enter  the  thorax  either  in  front  of  or  behind  the  sub- 
clavian artery." 

Section  VI.,  nearly  one-third  of  the  entire  work,  is  devoted  chiefly  to 
the  organs  of  sense,  of  digestion,  of  respiration,  and  the  genito-urinary 


1885.] 


Allen,  A  System  of  Human  Anatomy. 


229 


organs;  the  last  fifty  pages  being  given  to  superficial  anatomy,  to  malfor- 
mations, and  to  the  method  of  making  post-mortem  examinations. 

Neither  time  nor  space  permits  of  any  detailed  consideration  of  the 
thorough  and  excellent  way  in  which  are  treated  the  numerous  and  im- 
portant subjects  of  the  first  part  of  this  section.  The  eye,  the  ear,  the 
nose,  the  month,  the  larynx,  the  lungs,  and  the  whole  alimentary  and 
genito-urinary  tracts,  with  their  appended  organs,  are  here  found  treated 
of,  and  the  sub-section  closes  with  a  description  of  the  skin  and  nails. 
Reference  must  be  made,  in  passing,  to  the  valuable  table  (from  L.  Mayer) 
given  in  the  sub-section  on  the  liver,  and  "  designed  to  show  the  character 
of  the  lesions  of  internal  organs  accompanying  gunshot  and  other  wounds 
in  the  neighborhood"  of  that  viscus.  The  page-heading  "  organs  of  sense" 
has  been  carried  over  quite  a  distance  into  the  part  of  the  work  devoted  to 
the  "organs  of  digestion." 

Of  the  second  part  of  the  section,  nearly  one -half  the  pages  are  devoted 
to  superficial  and  topographical  anatomy ;  a  subject  the  value  of  which 
every  anatomical  teacher  must  recognize,  while  at  the  same  time  fully 
aware  how  little  knowledge  of  it  is  possessed  by  students  in  general. 
Though  in  the  various  text-books  of  late  years  published  in  Great  Britain 
and  our  own  country,  increasing  attention  has  been  given  to  this  surface 
anatomy  of  the  living  body,  still  in  no  one  of  them  is  the  treatment  of  the 
subject  anything  like  so  full  and  instructive  as  here. 

In  the  pages  in  which  is  given  "a  brief  outline  of  those  phases  of  em- 
bryology which  may  be  held  to  be  useful  in  studying  congenital  defects,"  the 
author  discusses  the  causes  and  varieties  of  malformations,  the  parts  of  the 
embryo  in  which  they  occur,  and  the  forces  which  underlie  the  congenital 
forms.  Forster's  classification  (with  his  well-known  figures)  is  presented, 
Foster  and  Balfour's  writings  on  foetal  development  are  freely  quoted,  and 
a  number  of  Dalton's  familiar  plates  are  introduced.  In  writing  of 
"  Errors  of  Mesoblastic  Origin"  it  is  suggested  that  "it  would  be  a  useful 
tentative  position  for  the  pathologist  to  accustom  himself  to  view  many 
forms  of  morbid  growth,  particularly  the  myxomata  and  sarcomata,  as  ex- 
pressive of  mesoblastic  development  occurring  out  of  place  and  order." 
Exception  is  taken  to  the  use,  aside  from  its  convenience,  of  the  term 
"twin,"  in  speaking  of  double  monsters:  "A  twin,  strictly  speaking,  is 
one  of  two  born  at  a  birth.  A  double  monster  is  a  single  individual,  and, 
as  such,  arises  from  a  single  blastodermic  membrane  overlying  a  single 
vitellus." 

For  the  making  of  post-mortem  examinations  very  full  and  precise  rules 
are  given.  In  the  opening  of  the  abdomen,  it  is  recommended  to  make  a 
transverse  incision  just  above  or  below  the  umbilicus.  In  private  practice 
it  is  generally  more  advisable  to  add  to  the  longitudinal  incision  simply 
a  free  division  of  the  rectus  fibres  a  short  distance  above  the  pubes. 
When  special  attention  is  to  be  given  to  the  state  of  the  heart,  it  is 
directed  that  the  liver  be  left  in  position  "until  the  thorax  has  been 
opened  and  the  heart  examined."  For  the  removal  of  the  nasal  cham- 
bers and  the  ears  for  special  study  Schalle's  method,  "  undoubtedly  the 
best,"  is  recommended,  and  considerable  space  is  devoted  to  a  description 
of  it. 

To  this  section  is  appended  what  will  add  not  a  little  to  the  comfort  of 
those  using  the  work,  very  full  general  and  clinical  indices. 

Appearing,  as  it  has,  in  serial  parts,  it  is  only  now,  with  the  last  section 
in  hand,  that  any  just  estimate  can  be  formed  of  the  value  of  this  "  System 


230 


Reviews  . 


[Jan. 


of  Human  Anatomy."  Everywhere  throughout  the  work  appear  evidences 
of  the  immense  labor  connected  with  its  preparation,  and  of  the  author's 
constant  effort  to  present  with  the  anatomical  facts  such  clinical  appli- 
cations as  may  at  once  illustrate  and  impress  them.  Whether  to  the 
ordinary  student  "  receiving  first  impressions  of  this  great  subject," 
such  "  union  of  the  descriptive  and  the  clinical  data"  is  of  service,  is  a 
question  ;  but  there  can  be  no  doubt  of  its  great  value  to  one  more  ad- 
vanced, especially  to  the  general  practitioner,  from  whose  mind  unapplied 
anatomical  details  so  easily  and  so  quickly  slip  away.  To  such  practi- 
tioner the  work  under  review  will  be  a  perfect  treasure-house  of  knowledge, 
to  which  he  will  turn  again  and  again. 

Until  a  later  edition  may  appear,  free  from  the  numerous  errors  that  now 
mar  the  work  and  seriously  impair  its  value,  the  reader  should  be  in  posses- 
sion of  such  knowledge  of  descriptive  data  as  will  enable  him  to  make  the 
necessary  corrections.  Though,  almost  without  exception,  the  present 
errors  are  such  as  might  and  would  have  been  at  once  avoided  had  there 
been  more  careful  revision  of  the  proof,  yet  no  one  knows  better  than  the 
author  that,  as  an  anatomical  statement  is  either  exactly  right  or  exactly 
wrong,  absolute  accuracy  must  characterize  any  work  which  will  be  accepted 
as  an  authority.  Freed  from  its  blemishes,  "  Allen's  Anatomy"  would  re- 
ceive from  every  one  merited  praise  as  the  most  valuable  work  on  anatomy 
published  in  the  English  language,  and  from  such  blemishes  it  can  easily 
be  freed.  The  more  it  is  studied  the  more  valuable  it  appears,  and  the 
more  apparent  becomes  the  obligation  the  reader  is  under  to  its  distin- 
guished author,  whose  industry  and  learning  have  brought  together  and  in 
relation  such  a  multitude  of  descriptive  data,  and  of  clinical  facts  bearing 
thereon.  P.  S.  C. 


Art.  XXXI — Index- Catalogue  of  the  Library  of  the  Surgeon-  General' 's 
Office,  United  States  Army.  Authors  and  Subjects.  Vol.  v.  Flaccus- 
Hearth.  4to.  pp.  [ii]  1055.  Government  Printing  Office,  Washington, 
1884. 

From  the  summary  of  the  contents  of  this  volume  contained  in  the 
brief  prefatory  report  of  Dr.  Billings  we  learn  that  it  includes  15,555 
author-titles,  representing  5755  volumes  and  12,596  pamphlets.  It  also 
includes  8069  subject-titles  of  separate  books  and  pamphlets,  and  34,127 
titles  of  articles  in  periodicals. 

All  this  vast  list  is  classified  according  to  the  rules  which  have  obtained 
in  the  arrangement  of  the  previous  volumes.  Those  rules  are  such  as 
have  received  the  approbation  of  librarians  generally,  and  even  were  this  not 
the  case,  the  decision  of  so  competent  an  authority  as  the  gentleman  who 
has  done  this  work,  with  such  an  abundance  of  material  at  command, 
would  be  enough  to  establish  the  rule.  We  speak  of  these  methods  as 
those  generally  approved,  but  no  system  of  classification  yet  adopted  in 
medical  literature  has  received  unanimous  consent.  To  each  one  there 
are  objections  which  can  be  fairly  urged,  and  none  which  will  meet  all  re- 
quirements. Thus  gastrostomy  and  gastrotomy  are  both  included  under 
the  latter  title,  and  the  reader  is  pointed  by  cross  reference  to  abdominal 
and  Cesarean  section,  to  fistula,  intestines,  ovariotomy,  pregnancy,  and 


1885.] 


Ralfe,  Clinical  Chemistry. 


231 


stomach  for  further  information  on  the  subject.  Indeed  most  of  the  titles 
referred  to  under  this  head  are  of  cases  which  accurately  writing  surgeons 
generally  speak  of  as  gastrostomies.  On  the  other  hand,  however,  it  may 
with  propriety  be  urged  that  whenever  the  belly  is  opened  by  incision  a 
gastrotomy  is  done,  whether  the  object  be  to  form  a  mouth  there,  to  re- 
move a  growth  or  foreign  body,  to  remedy  an  obstruction,  or  repair  an 
injury.  AYe  incline  to  the  opinion  that  it  would  have  been  more  precise 
to  term  all  cases  in  which  gastrotomy  was  done  for  the  purpose  of  establish- 
ing a  mouth,  gastrostomies,  even  though  many  of  those  reporting  them 
make  use  of  the  more  general  title. 

Eleven  pages  are*  occupied  with  additions  to  the  list  of  medical  periodi- 
cals, and  their  abbreviations,  employed  in  the  Index-catalogue,  thereby 
indicating  undiminished  care  in  the  final  preparation  of  the  volume  for  the 
press. 

Of  the  value  of  this  catalogue  we  have  repeatedly  spoken  in  previous 
notices,  as  the  successive  volumes  have  appeared,  and  we  can  only  empha- 
size those  opinions  now.  To  the  scientific  medical  worker,  the  library  of 
the  Surgeon-general's  office  is  simply  of  inestimable  value,  and  to  a  proper 
use  of  it  a  catalogue  is  indispensable.  By  consulting  the  pages  of  the 
Index-catalogue  in  any  neighboring  public  library  the  student  can  learn 
what  this  great  repository  at  Washington  contains  suited  to  his  need,  and 
can  either  secure  the  loan  of  the  required  volumes,  under  a  suitable  guar- 
antee, or  can,  like  Carlyle,  when  he  visited  Germany  to  secure  materials 
for  his  life  of  Frederick  the  Great,  make  a  pilgrimage  to  the  American 
Capital,  and  consult  its  treasures  on  the  spot.  In  adopting  this  latter 
course,  he  will  find  every  facility  afforded  him  for  a  thorough  examination 
of  the  books  he  wishes  to  consult,  and  it  is  to  be  hoped  he  may  do  so 
without  the  absurdly  amusing  discomforts  which  attended  all  the  journeys 
of  the  Chelsean  sage. 

Now  that  the  fever  of  political  excitement  is  in  some  measure  abated, 
it  is  to  be  hoped  that  Congress  may  be  persuaded  to  give  proper  consider- 
ation to  the  claims  of  this  great  library,  may  resist  the  attempt  to  merge 
it  in  the  Congressional  library,  may  provide  it  with  a  suitable  fire-proof 
building  of  its  own,  and  may  make  such  adequate  appropriations  as  will 
permit  of  a  speedy  issue  of  the  remaining  volumes  of  the  invaluable  Index- 
catalogue.  S.  A. 


Art.  XXXII  Clinical  Chemistry.     By  Charles  Henry  Ralfe, 

M.A.,  M.D.,  Cantab.,  Fellow  of  the  Royal  College  of  Physicians, 
London,  Assistant  Physician  at  the  London  Hospital,  etc.  16mo.,  pp. 
308.    Philadelphia:  Henry  C.  Lea's  Son  &  Co.,  1884. 

Phe  Elements  of  Physiological  and  Pathological  Chem  istry.  By  T.  Cr  ans- 
toyvn  Charles,  M.D.,  Fellow  of  the  Chemical  Society  and  Royal 
Medical,  Chirurgical,  and  Pathological  Societies ;  Demonstrator  of 
Physiology  and  Physiological  Chemistry,  St.  Thomas's  Hospital  Med- 
ical School,  etc.  Large  8vo.,  pp.  463.  Philadelphia  :  Henry  C.  Lea's 
Son  &  Co.,  1884. 

The  above  two  works  are  very  similar  in  their  general  scope  and  cha- 
racter ;  and  appearing,  as  they  do,  almost  simultaneously,  they  may  very 
naturally  become  the  subjects  of  one  common  review. 


232 


Reviews. 


[Jan. 


No  argument  is  needed  to  justify  the  important  position  now  universally- 
conceded  to  chemistry  by  the  educated  physician,  especially  in  clinical 
teaching.  To  it  and  to  the  microscope  are  we  particularly  indebted  for 
the  rapid  advances  made  within  the  last  quarter  of  a  century  in  histologi- 
cal, pathological,  and  therapeutical  studies.  The  recognition  of  this  fact 
is  evinced  in  the  very  general  prominence  now  given  by  our  medical 
schools  to  laboratory  chemical  work,  as  an  essential  part  of  the  student's 
education.  There  is  certainly  no  lack  of  excellent  treatises  in  this  depart- 
ment of  medical  science,  both  domestic  and  foreign  ;  but  without  depreci- 
ating others,  we  can  aver,  after  a  somewhat  careful  perusal  of  their  contents, 
that  the  present  volumes  treat  of  the  subjects  described  in  a  highly  satis- 
factory manner. 

1.  The  first  admirable  little  work  constitutes  one  of  the  series  of  manuals 
originally  published  by  Cassells,  of  London,  and  which  the  Messrs.  Lea, 
of  this  city,  have  so  opportunely  laid  before  the  profession  of  our  own 
country.  It  contains  a  succinct  and  graphic  "  account  of  the  analysis  of 
blood,  urine,  morbid  products,  etc.,  with  an  explanation  of  some  of  the 
chemical  changes  that  occur  in  the  body  in  disease." 

The  author  is  evidently  master  of  his  subject.  His  style  is  clear  and 
unpretentious  ;  his  description  of  chemical  processes  and  results  perfectly 
intelligible  to  the  advanced  student ;  and  his  "  explanations  of  the  chemical 
changes  that  occur  in  the  body  in  disease"  are  very  suggestive  to  the 
practising  physician. 

Commencing  with  a  succinct  enumeration  of  the  organic  and  inorganic 
constituents  of  the  human  body,  the  author  proceeds  to  group  and  classify 
these  principles  under  appropriate  heads,  such  as  Saccharine  and  Starchy 
Principles,  Fatty  Principles,  Proteid  Principles,  Products  of  Metabol- 
ism, Non-nitrogenous,  and  Nitrogenous,  and  not  omitting  a  brief  men- 
tion of  Ptomaines,  or  the  alkaloids  of  putrefaction.  The  chapters  on 
Blood  and  Urine  are  well  up  to  our  present  knowledge  in  these  depart- 
ments. We  notice,  in  passing,  when  treating  of  blood-stains,  that  an  ap- 
parent (though  doubtless  unintentional)  slight  is  put  upon  the  guaiacum- 
test  by  the  statement  that  "  other  substances  besides  blood  give  this  (the 
bluing)  reaction  with  guaiacum."  This  is  true,  but  with  the  reservation 
that  with  blood  it  takes  place  immediately,  whilst  with  other  substances 
time  is  required.  The  description  of  the  "  Toxic  Condition  of  the  Blood" 
is  lucid  and  instructive.  The  chapter  on  the  urine  is  the  fullest  in  the 
book,  occupying  seventy  pages,  but  is  not  more  copious  than  its  import- 
ance justifies.  The  subject  is  treated  in  a  very  satisfactory  manner,  first 
chemically,  and  then  in  its  pathological  and  clinical  bearings.  All  the 
latest  and  best  urinary  tests  are  clearly  described,  so  as  to  be  easily  fol- 
lowed by  the  advanced  student.  We  notice  one  little  lapsus  in  connection 
with  the  "  detection  of  lead  in  urine,"  which  is  of  some  practical  im- 
portance to  the  working  chemist,  in  the  direction  to  incinerate  the  extract 
containing  the  lead,  "  in  a  platinum  or  porcelain  crucible  ;"  there  would 
be  a  risk  (as  the  chemist  knows)  of  seriously  injuring  the  platinum  by 
heating  it  with  lead. 

In  the  directions  for  "  detecting  mercury  in  the  saliva,"  we  think  the 
author's  method  unnecessarily  complex.  We  have  always  deemed  it  suffi- 
ciently satisfactory  simply  to  employ  Reinsch's  test  to  the  saliva  directly. 
The  mercurial  deposit  on  the  copper  can  readily  be  identified. 

In  the  account  of  the  gastric  juice,  the  author's  view  is  very  decided 


1885.] 


Ralfe,  Clinical  Chemistry. 


233 


as  to  hydrochloric  acid  being  the  true  cause  of  its  normal  acidity.  For 
years  past,  it  has  been  a  vexed  question  whether  it  was  due  to  this  acid, or 
to  lactic  acid.  We  may  regard  the  matter  as  now  definitely  settled. 
Richet  has  shown  that  in  the  fresh  secretion,  hydrochloric  acid  is  the  only 
one  present.  Lactic,  acetic  and  butyric  acids  are  met  with  "  only  as  re- 
sults of  fermentive  changes  occurring  in  the  stomach."  In  certain  mor- 
bid conditions,  these  acids  may  be  considerably  in  excess  of  hydrochloric 
acid.  The  author  points  out  the  practical  importance  of  discriminating 
between  the  normal  and  the  abnormal  acids,  in  case  of  acid  dyspepsia ; 
and  he  gives  Richet's  method  of  distinguishing  them  in  the  vomited  mat- 
ters. Under  this  same  head,  some  sound  practical  hints  are  given  for  the 
detection  of  poisons  in  the  vomit,  which  any  educated  physician  should  be 
able  to  employ  in  an  emergency,  as  trial  tests. 

In  the  section  on  Bile,  along  with  a  good  account  of  the  chemistry  of 
this  secretion,  the  author's  clinical  remarks  on  jaundice  and  diabetes  are 
both  valuable  and  suggestive. 

Under  the  heading  of  the  "  Detection  of  Arsenic,  Antimony,  etc.,  in 
the  Viscera,"  we  are  compelled  to  notice  another  chemical  inadvertence 
on  the  part  of  the  author,  in  the  mode  of  employment  of  the  excellent 
method  of  Reinsch.  He  recommends  this  process  to  be  used  on  the  acid 
mixture  obtained  by  the  previous  employment  of  potassium  chlorate  on  the 
original  material;  whereas  (as  the  chemist  well  knows),  in  the  latter  case 
the  liberated  chlorine  would  indirectly  prevent  the  arsenic  or  antimony 
from  being  deposited  on  the  copper. 

The  last  chapter  treats  of  "  Morbid  Products,"  including  urinary,  bili- 
ary, and  pancreatic  calculi,  intestinal,  gouty,  and  other  concretions,  pro- 
ducts of  various  degenerations,  morbid  exudations,  and  clinical  remarks 
on  scurvy,  gout,  and  rheumatism,  from  a  chemical  standpoint.  We  take 
pleasure  in  recommending  this  manual  both  to  the  student  and  physician 
as  as  excellent  resume  of  clinical  chemistry,  and  as  a  safe  and  practical 
guide  in  this  most  interesting  department  of  medical  study. 

2.  The  treatise  of  Dr.  Charles  is  a  more  elaborate  production,  and  deals 
with  the  subject  more  from  the  physiological  and  pathological  standpoint 
than  from  the  purely  clinical.  The  author  discusses  his  subject  under  the 
four  main  heads  of — I.  Nutrition  and  Foods  ;  II.  Digestion  and  the  Se- 
cretions concerned ;  III.  The  Chemistry  of  the  Tissues,  Organs,  and 
remaining  Secretions  ;  IV.  The  Excreta,  the  Feces,  and  Urine.  Under 
these  several  divisions  ample  scope  is  given  for  treating  of  various  kinds 
of  foods,  nitrogenous  and  non-nitrogenous  ;  describing  the  most  approved 
methods  of  analyzing  them,  both  qualitatively  and  quantitatively,  with 
approximate  reference  to  their  physiological  bearing.  The  chapter  on 
"  Digestion  and  the  Secretions  Concerned,"  are  full  of  valuable  matter, 
lucidly  expressed  and  amply  illustrated  by  appropriate  experiments,  most 
useful  for  the  advanced  student  to  follow  in  his  laboratory  researches. 
Under  the  head  of  "  The  Chemistry  of  the  Tissues,  etc.,"  the  blood  very 
naturally  claims  and  receives  a  large  and  careful  description  in  its  chemi- 
cal, physiological,  and  pathological  relations.  We  have  seen  no  better 
treasise  on  this  subject  since  the  issue  of  Lehman's  well-known  work,  now 
becoming  almost  obsolete.  Under  this  same  heading,  the  author  gives  us 
an  excellent  description  of  muscle,  nerve,  milk,  and  the  function  of  respi- 
ration, each  subject  containing  the  views  of  the  latest  and  most  approved 
authorities.    Being  himself  a  pupil  of  the  distinguished  Prof.  Hoppe- 


234 


Reviews. 


[Jan. 


Seyler,  he  is  enabled  the  more  confidently  to  refer  to  the  experiments  and 
deductions  of  that  celebrated  teacher. 

In  the  chapters  devoted  to  the  consideration  of  "  The  Excreta,"  the 
urine  very  properly  receives  a  most  thorough  and  careful  consideration, 
which  leaves  nothing  further  to  desire  as  a  safe  guide  for  the  physiologi- 
cal and  pathological  student. 

The  last  chapter  contains  a  very  useful  syllabus,  or  guide,  for  the  stu- 
dent's practical  working  out  the  various  chemical  and  physiological  pro- 
cesses previously  discussed,  which  should  certainly  be  welcomed  by  him 
as  a  real  help  in  his  laboratory  investigations. 

We  entertain  a  high  opinion  of  Dr.  Charles's  treatise,  and  regard  it  as 
a  most  useful  work,  not  only  for  students  of  physiological  chemistry,  but 
also  as  being  suggestive  for  teachers  of  this  science.  It  is  illustrated  with 
a  number  of  good  engravings,  and  with  an  excellent  chromo-lithograph  of 
the  blood-spectra.  J.  J.  R. 


Art.  XXXIII  The  Elements  of  Pathology.     By  Edward  Rind- 

fleisch,  M.D.,  Professor  of  Pathological  Anatomy  in  the  University 
of  Wurzburg.  Translated  from  the  First  German  Edition,  by  Wm. 
H.  Mercur,  M.D.  (University  of  Pennsylvania).  Revised  by  James 
Tyson,  M.D.,  Professor  of  General  Pathology  and  Morbid  Anatomy  in 
the  University  of  Pennsylvania,  etc.  etc.  12mo.  pp.  263.  Philadelphia  : 
P.  Blakiston,  Son  &  Co.,  1884. 

The  rare  good  judgment  of  the  translator  and  reviser  of  this  excellent 
work  has  resulted  in  putting  into  the  hands  of  American  medical  students 
a  book  which  has  long  been  needed,  and  in  a  form  which  adds  the  charm 
of  graceful  diction  to  the  substantial  value  of  comprehensive  accuracy. 
Indeed,  when  we  compare  this  admirable  translation  with  the  rugged  and 
obscure  sentences  disfiguring  Professor  Rindfleisch's  great  Text-book  of 
Pathological  Histology,  when  it  first  appeared  in  English  dress  in  the 
original  edition  of  1872,  we  feel  both  that  Professor  Tyson  and  Dr.  Mercur 
deserve  the  highest  praise  for  overcoming  the  well-known  difficulties 
of  their  task,  and  that  the  intrinsic  worth  of  the  labors  of  Dr.  Rindfleisch 
must  be  truly  great,  to  enable  his  reputation  to  survive  the  malrepresenta- 
tion  with  which  it  came  before  the  medical  profession  of  the  United  States. 
In  our  opinion  the  modest  claim  made  by  the  reviser  in  his  generous  pre- 
face that  most  of  the  well-recognized  difficulties  of  translation  have  been 
surmounted,  is  most  amply  sustained,  and  his  assurance  that  he  has  read 
every  line  of  proof,  and  carefully  compared  all  doubtful  passages  with  the 
original,  explains,  perhaps,  the  exceptional  clearness  of  the  language 
employed,  and  certainly  confirms  our  confidence  in  the  correctness  with 
which  it  conveys  the  genuine  meaning  of  the  Wurzburg  professor. 

The  general  plan  of  the  volume  is  that  of  considering,  first,  the  phe- 
nomena of  the  local  outbreak  of  disease  under  which  are  discussed  inflam- 
mation in  all  its  varieties,  and  the  formation  of  tumors  ;  next,  the 
anatomical  extension  of  disease,  comprising  the  deuteropathic  groups  of 
symptoms,  metastasis,  fever,  and  irritation  of  the  nervous  system;  then 
the  physiological  extension  of  disease,  including  the  vegetative  and  animal 
disturbances,  is  explained  at  considerable  length ;  and,  lastly,  a  special 


1885.] 


Rosenbach,  Musical  Heart  Murmurs. 


235 


part  is  devoted  to  the  traumatic  affections,  the  parasitic  and  infectious 
diseases,  disorders  from  defective  development  or  growth,  those  from  over- 
work, and  those  accompanying  involution. 

In  regard  to  the  most  important  question  of  the  day  in  pathology,  prac- 
tical medicine,  and  hygiene,  Dr.  Rindfleisch  declares  himself  an  unreserved 
supporter  of  the  germ  theory  of  diseases,  and  devotes  a  score  of  pages  to 
descriptions  of  the  various  fungi,  which  have  been  definitely  pronounced 
the  exclusive  causes  of  well-known  infectious  maladies.  Nearly  all  of 
these  are  grouped  in  the  class  of  schizophytes,  or  cleft  fungi,  the  smallest 
plants,  and,  indeed,  the  most  minute  of  living  creatures.  Our  author 
asserts  that,  although  we  are,  as  yet,  only  on  the  threshold  of  the  science  of 
microphytic  disturbances  of  health,  many  of  these  pathogenetic  organisms 
may  be  made  distinct  by  using  proper  staining  fluids  and  good  illumina- 
tion, so  that  we  already  have  at  command  much  definite  information  in 
regard  to  their  natural  history.  Besides  the  comparatively  well-known 
schizophytes  of  relapsing  fever,  splenic  fever,  and  actinomycosis,  the 
micrococcus  erysipelas,  the  bacillus  Kochii  of  tuberculosis,  the  microphyton 
gonococcus  found  in  the  pus  corpuscles  of  gonorrhoea,  and  the  bacillus 
lepras  are  described  in  detail. 

In  regard  to  the  much-disputed  questions  of  acclimation  of  a  pathoge- 
netic microphyte  to  its  habitat,  and  vice  versa,  which  bear  such  important 
relations  to  the  doctrines  of  Pasteur  in  regard  to  the  attenuation  of  virus, 
Professor  Rindfleisch  accepts  as  conclusive  the  experiments  of  Buchner  and 
Nageli,  which  seem  to  show  that  a  certain  hay  fungus  (the  B.  subtilis)  can 
be  gradually  acclimated  to  the  conditions  of  development  in  living  human 
blood,  where  it  can  ultimately  vegetate  with  all  the  terrible  pathogenetic 
power  of  B.  anthracis. 

As  this  work  will  probably  be  placed  upon  the  list  of  text-books  on 
pathology  in  most  of  our  well-equipped  medical  colleges,  a  second  edition 
will  no  doubt  be  speedily  called  for.  We  would  suggest  that,  among  other 
slight  verbal  changes  in  the  new  edition,  pearly  should  be  substituted  for 
"  pearJ-sized,"  in  describing,  on  page  184,  the  vesicles  of  herpes;  that  amount 
would  be  better  than  "  value,"  in  speaking  of  such  a  worthless  thing  as 
functional  disturbance  on  page  188,  and  that  "cohabitation,"  in  the  usual 
meaning  of  the  word,  is  more  apt  to  cause  temporary  hyperaesthesia  than 
deterioration  of  the  sense  of  smell,  as  intimated  on  page  189,  under  the 
bead  of  chemical  trauma.  J.  G.  R. 


Art.  XXXI V — Ueber  Musikalische  Herzger'dusche.  Nebst  Bemerhun- 
gen  uher  die  Entstehung  Pseudohardialen  Gerausche.  Von  Dr.  Otto- 
mar  Rosenbach,  Privat-dozent  an  der  Universitat  Breslau.  8vo. 
pp.  22.    Wien,  1884. 

Musical  Heart  Murmurs,  with  Remarks  on  the  Occurrence  of  Pseudo- 
Gardial  Murmurs.    By  Dr.  Ottomar  Rosenbach. 

This  little  brochure,  No.  iii.  of  Schnitzler's  Wiener  Klinih  for  last 
year,  presents  a  subject  little  considered  in  the  text-books  in  a  thorough 
and  attractive  way.  It  is  safe  to  say  that,  notwithstanding  the  differ- 
ences in  the  German  methods  of  literary  treatment  of  scientific  subjects 


236 


Reviews. 


[Jan. 


and  our  own,  no  one  at  all  interested  in  the  clinical  study  of  diseases  of 
the  heart  will  begin  the  reading  of  this  lecture  without  finishing  it.  Nor 
will  those  so  interested  be  willing  to  be  without  it  for  future  reference. 
It  is  a  well-conceived  and  well-worked  out  tractate,  brief  as  it  is. 

Musical  murmurs  in  the  region  of  the  heart  have  always  had  an  extreme 
interest  for  those  who  have  encountered  them,  partly  because  of  their 
striking  acoustic  characters,  partly  because  of  the  obscurity  of  their  origin, 
and  the  frequent  failure  of  the  condition  of  the  heart  after  death  to  ex- 
plain their  occurrence. 

Of  late,  this  interest,  as  attested  by  numerous  contributions  to  the  sub- 
ject in  current  medical  literature,  appears  to  have  taken  fresh  life. 

Dr.  Rosenbach's  conclusions  are  based  upon  clinical  experience,  post- 
mortem investigations,  and  upon  experimental  research.  He  holds  that 
the  cause  and  the  mode  of  origin  of  musical  murmurs  can  be  best  studied 
by  avoiding  the  error  of  restricting  the  attention  too  closely  to  the  heart 
itself,  and  by  paying  due  regard  to  all  the  phenomena  having  the  charac- 
ters of  musical  murmurs  that  occur  in  the  chest.  Only  thus  can  we  sepa- 
rate the  essential  and  the  accidental  factors,  determine  that  which  is  the 
same  in  causation  everywhere,  and  place  the  subject  upon  the  simplest 
basis. 

Since  it  may  be  affirmed  that  wherever  musical  murmurs  of  the  same 
acoustic  properties  arise,  the  same  or  similar  physical  conditions  are 
present,  and  since,  further,  exquisite  musical  murmurs  are  frequently  pro- 
duced in  the  veins,  and,  under  certain  conditions  of  disease,  in  the  bron- 
chial tubes,  it  is  necessary  to  compare  the  causal  conditions  here  existing, 
which  have  been  thoroughly  studied,  with  those  of  musical  heart  murmurs, 
and  to  regard  those  which  are  common  to  all  as  essential  in  the  production 
of  the  musical  character  in  the  murmurs.  When  this  has  been  done,  and 
the  simple  mechanism  by  which  such  phenomena  are  caused  has  been 
cleared  up,  then  can  we,  instead  of  enumerating  a  scarcely  classifiable 
multitude  of  pathologico-anatomical  conditions,  in  which  musical  murmurs 
have  occurred  during  life,  explain  their  occurrences  in  accordance  with 
definite  physical  laws. 

Improbable  as  it  at  first  sight  appears  that  acoustic  phenomena,  which 
seem  to  be  simply  the  product  of  special  modifications  of  the  cardiac 
mechanism,  and  in  particular  of  lesions  of  the  aortic  valves,  may  arise 
outside  the  heart,  yet  a  little  reflection  will  convince  us,  a  priori,  that 
such  is  the  case. 

We  know  that  rhythmical  murmurs  are  not  only  due  to  the  blood-stream 
within  the  heart,  but  also  to  the  influence  exerted  by  the  rhythmical 
changes  of  the  volume  of  that  organ  upon  the  neighboring  organs,  veins, 
and  lungs ;  and  further,  that  musical  murmurs  are  merely  special  acoustic 
modifications  of  ordinary  blowing  or  humming  heart  murmurs  ;  it  may 
therefore  be  assumed  that  musical  murmurs  of  cardiac  rhythm  also  may 
sometimes  owe  their  origin  to  the  pressure  of  the  heart  upon  other  or- 
gans. 

The  author  regards  this  as  a  very  much  more  frequent  cause  of  musi- 
cal murmurs  than  it  has  been  thought  to  be. 

The  conditions  under  which  musical  murmurs  are  produced  in  the  lungs 
by  respiration  are  well  understood,  as  also  is  the  mechanism  of  venous 
murmurs  of  various  acoustic  characters.  From  the  present  point  of  view, 
then,  it  may  be  possible  to  differentiate  the  groups  of  musical  heart  mur- 
murs according  to  their  places  of  origin,  and  to  point  out  more  exactly 


1885.] 


Rosenbach,  Musical  Heart  Murmurs. 


237 


the  conditions  under  which  the  blood-stream  within  the  heart  produces 
musical  murmurs. 

Murmurs  produced  outside  the  heart  by  the  reaction  of  the  mechanism 
of  that  organ  upon  neighboring  organs  may  be  termed  pseudo-cardial 
murmurs. 

The  most  common  form  of  musical  murmurs  having  the  cardiac  rhythm, 
yet  originating  outside  the  heart,  is  that  which  is  produced  by  air  cur- 
rents, caused  by  the  change  in  shape  and  by  the  locomotion  of  the  heart, 
in  certain  regions  of  the  lung  bordering  upon  the  heart.  Owing  to  the 
anatomical  relations  in  the  region  of  the  apex,  it  is  here  and  over  the  body 
of  the  heart,  especially  towards  its  left  border,  that  murmurs  of  this  kind 
are  most  frequent  and  loudest.  Auscultatory  signs  both  of  health  and  of 
disease  may  thus  have  respiratory  characters  and  cardiac  rhythm  in  localized 
areas.  The  vesicular  murmur  may  be  heard  in  health,  all  kinds  of  rales 
in  disease.  The  same  mechanism  is  the  cause  of  pulmonary  murmurs 
having  the  cardiac  rhythm  in  the  region  of  the  great  vessels,  the  volume 
of  which  also  undergoes  considerable  variations  in  systole  and  diastole, 
and  a  third  region  of  predilection  is  that  of  the  bifurcation  of  the  trachea. 

These  murmurs  may  be  greatly  modified,  sometimes  even  made  to 
vanish  by  deep  inspiration,  by  forced  expiration,  by  changes  in  posture, 
and,  finally,  by  firm  pressure  over  the  region  in  which  they  are  heard  ;  a 
fact  not,  or  at  all  events  but  to  a  very  slight  degree,  observed  in  endocardial 
murmurs.  When  such  pseudo-cardial  murmurs  are  of  a  musical  character, 
they  are  associated,  for  the  most  part,  with  rales  having  a  similar  char- 
acter elsewhere  in  the  lungs. 

A  second  group  of  pseudo-cardial  murmurs  have  their  origin  in  the 
veins.  Here,  as  has  long  been  known,  musical  phenomena  occur  which, 
by  reason  of  their  acoustic  properties  and  their  rhythmical  character, 
may  be  easily  mistaken  for  true  heart  murmurs.  This  error  in  diagnosis 
is  the  more  likely  to  take  place,  because  the  auscultatory  phenomena 
usually  produced  in  the  veins  are  not  rhythmical  and  intermittent,  but 
continuous.  When,  however,  they  do  correspond  to  the  heart's  action,  and 
show  an  intensity  which  varies  with  the  force  of  the  heart,  the  resemblance 
is  very  close.  Especially  is  this  true  when,  as  occasionally  happens,  the 
murmur  is  transmitted  without  much  loss  of  intensity  to  the  base  of  the 
heart. 

Venous  murmurs  of  this  kind  are  mostly  simple  blowing  murmurs,  less 
frequently  singing  or  humming,  and  very  rarely  they  are  exquisitely 
musical.  They  are  strongest  during  inspiration,  and  occur,  by  preference, 
during  the  systole.  Diastolic  venous  murmurs  also  occur,  but  they  are 
rare.  They  differ  from  endocardial  murmurs  occurring  at  the  same  time, 
as  in  aortic  insufficiency,  in  that  they  are  heard  rather  in  the  beginning 
of  the  diastole,  and  are  never  so  long-drawn  out  as  true  aortic  murmurs, 
which  are  the  longest  in  duration  of  all  the  cardiac  signs  yielded  upon 
auscultation.  The  presence  or  absence  of  hypertrophy  of  the  left  ventri- 
cle is  an  important  differential  condition  in  cases  of  doubt.  These  venous 
murmurs  originate  in  the  vena  jugularis  dextra,  or  in  the  vena  anonyma ; 
those  having  the  latter  seat  of  origin  bearing  in  all  respects  the  closest 
resemblance  to  true  endocardial  murmurs. 

The  discrimination  of  musical  venous  murmurs  from  true  cardiac  mur- 
murs is  easy  in  proportion  to  the  distances  from  the  heart  of  their  seat  of 
origin  and  point  of  greatest  intensity.  Of  further  diagnostic  importance 
are  the  facts  that  the  venous  murmurs  are  always  proportionately  weaker, 
and  have  a  softer  quality,  and  that  they  are  very  apt  to  vary  in  intensity 


238 


Reviews. 


[Jan. 


from  timQ  to  time.  All  influences  which  tend  to  interfere  with  the  blood- 
stream in  the  veins,  in  which  such  murmurs  are  produced,  either  cause  the 
murmur  to  vanish,  or  so  modify  it  as  to  destroy  its  musical  character. 
The  horizontal  posture,  holding  the  breath,  pressure,  cause  this  effect  even 
when  the  murmur  originates  in  the  innominate.  Furthermore,  venous 
murmurs  are  developed  in  most  instances  in  anaemic  subjects,  and  dis- 
appear with  the  anaemia.  The  author  holds  the  view,  by  no  means  gene- 
rally accepted,  that  the  blowing  systolic  basic  murmurs  of  anaemia  are 
of  venous  and  not  of  cardiac  origin. 

In  addition  to  the  two  kinds  of  exocardial  murmurs  described,  there  is 
a  third  that  is  sometimes  musical  in  quality,  namely,  the  pericardial  fric- 
tion sound.  The  author's  observations  lead  him  to  believe,  contrary  to 
the  dictum  of  Skoda,  that  distinctly  musical  (whistling)  pericardial  fric- 
tion sounds  sometimes  occur,  hence,  that  pericardial  friction  may  simulate 
every  form  of  endocardial  murmur. 

Finally,  there  is  the  fourth  category,  which  comprises  true  endocardial 
musical  murmurs.  It  is  probable  that  many  cases  of  exocardial  murmurs 
are  clinically  referred  to  this  class. 

Dr.  Rosenbach  doubts,  on  physical  grounds,  and  believes  that  he  has 
experimentally  disproved,  the  possibility  of  the  production  of  musical  mur- 
murs within  the  heart  by  abnormal  or  supernumerary  chorda  tendinece. 
But  it  is  abundantly  proved  that  such  murmurs  may  be  caused  by  lesions  of 
the  valves  which  bring  about  regular,  clean-cut,  sharply  bordered  openings 
at  the  ostia  of  the  chambers  of  the  heart,  when  irregular  or  rough  deposits 
are  absent,  when  the  force  of  the  blood-stream  is  adequate  to  produce  a 
musical  tone,  and  when  the  conditions  are  favorable  to  the  conduction  of 
the  murmur  to  the  ear  of  the  auscultator.  For  the  reason  that  a  con- 
siderable degree  of  force  is  necessary  to  produce  a  murmur  having  a 
musical  quality,  these  murmurs  have  their  seat  of  origin  most  commonly 
at  the  aortic  orifice,  at  which  the  force  of  the  hypertrophied  left  ventricle 
is  most  directly  exerted.  The  paper  concludes  with  a  critical  study  of  the 
physical  conditions  under  which  musical  murmurs  arise  outside  of  and 
within  the  body,  and,  considered  in  its  entirety,  constitutes  an  important 
contribution  to  the  subject  of  which  it  treats.  J.  C.  W. 


Art.  XXXV — Bacteria.  By  Dr.  Antoine  Magnin  and  George  M. 
Sternberg,  M.D.,  F.R.M.S.  8vo.  pp.  xviii.,  494.  New  York  : 
William  Wood  &  Co.,  1884. 

Some  years  since,  Dr.  Sternberg  placed  us  under  obligation  for  his 
translation  of  the  excellent  volume  of  Magnin,  enhanced  in  value  by  the 
attractive  additions  of  his  photo-micrographs.  The  present  book  is  an 
extension  rather  than  a  revision  of  the  former,  presenting  so  much  new 
matter  from  the  pen  of  Dr.  Sternberg  that  his  name  justly  finds  its  place 
upon  the  title-page  as  joint  author. 

Bacteria,  in  its  newer  form,  is  divided  into  six  parts.  Parts  first  and 
second — Morphology  and  Physiology  of  the  Bacteria — contain  almost  the 
entire  matter  of  the  older  book,  with  but  slight  incidental  changes  in 
minor  details,  and  in  the  omission  of  those  subjects,  which  receive  full 


1885.] 


Magnin,  Sternberg,  Bacteria. 


239 


discussion  later  on.  Since  a  review  of  this  portion  of  the  work  has  already 
appeared  in  these  pages  (April,  1881),  it  will  be  unnecessary  to  more  than 
endorse  the  generally  favorable  opinion  already  expressed. 

The  remaining  four  parts — forming  two-thirds  of  the  volume,  and  treat- 
ing respectively  of  Technology,  Germicides  and  Antiseptics,  Bacteria  in 
Infectious  Diseases,  and  Bacteria  in  Surgical  Lesions — have  been  added 
by  the  American  author.  These  chapters  will  be  appreciated  by  two  dis- 
tinct classes  of  readers  :  the  working  biologist  in  search  of  useful  suggestions 
and  practical  hints  to  aid  his  laboratory  investigations  ;  and  the  critical 
student  who,  without  performing  laborious  experimentation,  desires  to  pre- 
sent to  himself  the  subject  of  disease  germs  in  an  intelligent,  scientific, 
and  impartial  manner. 

Under  the  heading  Technology  will  be  found  a  useful  resume  of  the 
various  modes  of  procedure  in  the  several  steps  incidental  to  this  line  of 
research.  The  section  on  Methods  of  Cultivation  includes  a  description 
of  culture-fluids,  sterilization,  culture  tubes  and  flasks,  etc.  As  culture- 
flasks,  those  made  by  the  author  from  glass  tubing,  being  quite  small  and 
having  a  very  long  and  delicate  neck,  are  highly  recommended,  and  cer- 
tainly seem  to  possess  decided  advantages.  Those  having  need  of  a 
means  of  obtaining  a  constant  temperature  will  find  useful  hints  for  the 
construction  of  efficient  thermostats  in  the  succeeding  pages.  The  section 
on  Staining  Bacteria  contains  the  better  known  methods  usually  em- 
ployed. For  bacteria  in  general,' an  aqueous  solution  of  methyl-violet — 
readily  obtainable  as  violet  ink — is  preferred.  Regarding  the  much- 
vexed  question  as  to  the  most  reliable  method  for  staining  the  tubercle 
bacillus,  our  author  contents  himself  with  giving  those  usually  employed, 
without  decidedly  committing  himself  to  an  expression  of  his  opinion  as 
to  relative  merits,  seeming,  however,  himself  to  prefer  Ehrlich's  method. 

In  connection  with  Photographing  Bacteria,  the  universal  experience 
of  those  who  have  attempted  this  with  B.  tuberculosis  is  indorsed,  and 
convincing  proof  of  the  difficulty  presented  in  the  figures  of  Plate  XI. 
Fig.  6,  declared  to  be  "  the  best  result"  obtained  by  so  expert  a  manipu- 
lator, will,  possibly,  carry  consolation  to  more  than  one,  who  has  had  but 
disappointment,  or  at  best,  perhaps,  a  shadowy,  ghostly  image  of  the 
bacillus  to  repay  for  hours  of  labor,  and  batches  of  plates  exhausted  in 
vain  attempts  to  "  catch  the  expression"  of  this  grim  monster.  In  this 
connection,  by  the  way,  we  trust  Dr.  Sternberg  will  put  to  trial,  if  he  has 
not  already  done  so,  the  value  of  employing  glass  of  a  color  complemen- 
tary to  that  of  the  staining,  somewhat  after  the  method  employed  by 
Koch.  Recently,  Defrenne  is  said  to  have  presented,  before  the  Belgian 
Microscopical  Society,  photographs  of  this  bacillus  of  exceptional  excel- 
lence, obtained  by  filtering  the  light  through  green  glass,  the  staining 
being  fuchsin. 

Part  Fourth — Germicides  and  Antiseptics — is  devoted  to  a  presentation 
of  the  results  of  an  exhaustive  series  of  experiments  with  over  sixty  sub- 
stances to  determine  their  relative  values  in  the  role  of  germicides.  A 
careful  examination  of  the  list,  alphabetically  arranged,  will  prove  of 
value  to  every  practitioner,  resulting,  possibly,,  in  the  abandonment  of 
some  favorite  solution  for  one  proved  to  be  more  worthy  of  confidence. 
The  fact  that  "  germicides  are  also  antiseptics,  .  .  .  but  an  antisep- 
tic is  not  necessarily  a  germicide"  is  worthy  of  general  recognition. 
These  experiments  were  very  carefully  performed,  and  the  convenient 
summary  will  prove  valuable  for  reference. 


240 


Reviews. 


[Jan. 


Part  Fifth — Bacteria  in  Infectious  Diseases — occupies  over  a  third  of 
the  entire  volume,  and  contains  matter  of  great  interest  to  every  student 
of  scientific  medicine.  After  some  excellent  comments  regarding  the 
value  of  various  kinds  of  evidence,  and  the  methods  of  conducting  cru- 
cial tests,  the  author  passes  in  critical  review  the  infectious  diseases — 
those  affecting  the  lower  animals  as  well  as  man — for  which  a  specific 
causal  micro-organism  has  been  described.  Space  forbids  a  detailed  ac- 
count of  the  subjects  discussed  ;  suffice  it  to  say  that  a  perusal  of  this  por- 
tion of  the  book  will  demonstrate  what  searching  scrutiny  is  indispensable 
for  a  correct  appreciation  of  the  value  of  investigations  in  this  difficult 
field.  For  this  reason,  the  criticisms  offered  by  one  so  admirably  quali- 
fied as  censor  as  is  our  author,  are  extremely  valuable  as  guides  to  those 
desiring  to  be  able  to  form  trustworthy  decisions  for  themselves. 

The  final  part  of  the  volume  relates  to  Bacteria  in  Surgical  Lesions, 
where  a  summary  of  the  opinions  of  many  foremost  in  this  field  of  obser- 
vation will  be  found,  together  with  notes  of  results  derived  from  the 
author's  own  experiments. 

The  book  closes  with  an  extensive  bibliography,  being  that  formerly 
appended  to  the  work  of  Magnin,  rearranged  alphabetically  instead  of 
chronologically,  and  rendered  more  complete  by  the  addition  of  numerous 
titles  of  recent  contributions  ;  we  notice,  however,  the  absence  of  the 
names  of  several  investigators,  whose  late  prominence  in  the  discussions 
regarding  tuberculosis  surely  entitles  them  to  a  place  in  so  comprehensive 
a  list. 

The  photo-micrographs  made  by  Dr.  Sternberg  are  generally  very  satis- 
factory, those  of  bacilli  and  of  blood  being  of  especial  excellence.  While 
thoroughly  appreciating  the  remarks  found  near  the  end  of  the  preface, 
we  trust  that  the  intimation  of  a  possible  omission  of  the  photographs  from 
subsequent  editions  will  not  be  carried  out.  In  this  field  drawings  are 
always  unsatisfactory,  and  to  those  sufficiently  interested  to  possess  the 
volume,  the  increased  cost  will  be  more  than  compensated  by  the  unim- 
peachable accuracy  of  the  sun-pictures.  Let  the  doctor  cultivate  the  de- 
mand for  greater  accuracy,  together  with  a  just  appreciation,  by  excellent 
photo-micrographs,  rather  than  descend  to  meet  the  request  for  the  time- 
honored  diagrammatic  drawing.  G.  A.  P. 


Art.  XXXYI. — Diseases  of  the  Brain  and  Spinal  Cord,  a  Guide  to  their 
Pathology,  Diagnosis,  and  Treatment,  with  an  Anatomical  and  Physio- 
logical Introduction.  By  David  Drummond,  M. A.,  M.D.,  Physician 
and- Pathologist  to  the  Newcastle-upon-Tyne  Infirmary,  Joint  Lecturer 
on  Pathology  in  the  University  of  Durham  College  of  Medicine.  8vo. 
pp.  374;  51  illustrations.    London:  Henry  Kimpton,  1883. 

We  think  Dr.  Drummond  did  wisely  in  taking  the  suggestion  of  his 
friends  and  issuing  as  a  small  volume  the  article  on  Diseases  of  the  Brain 
and  Cord  which  appeared  last  year  in  a  small  London  Journal,  The  News, 
devoted  to  the  interests  of  students.  In  its  present  form  the  work  is  an 
excellent  guide  to  the  study  of  diseases  of  the  nervous  system.  Many  of 
the  sections  are  brief,  but  the  more  important  affections  are  pretty  fully 


1885.]    Hat,  The  Physiological  Action  of  Saline  Cathartics.  241 


considered.  The  chapters  on  Syphilis,  Intracranial  Tumors,  and  General 
Paresis  are  very  good.  In  the  treatment  of  cerebral  syphilis  sufficient 
stress  is  not  laid  upon  the  importance  of  iodide  of  potassium,  or  upon  the 
need  of  large  doses.  The  section  on  General  Paresis  is  written  by  Dr. 
McDowell,  Superintendent  of  the  Northumberland  Asylum,  and  is  a 
valuable  addition  to  the  work. 

The  illustrations  are  simply  execrable,  badly  drawn  and  coarsely  ex- 
ecuted ;  anything  worse  than  Figs.  2  and  42  we  do  not  remember  to  have 
seen.  Mr.  Kimpton  is  only  beginning  to  issue  medical  works,  and  has 
everything  to  gain  by  attention  to  details  of  printing  and  illustration,  both 
of  which  he  has  in  this  instance  sadly  neglected.  W.  0. 


Akt.  XXXVII  An  Experimental  Investigation  of  the  Physiological 

Action  of  Saline  Cathartics.  By  Matthew  Hay,  M.D.  Edin.,  Prof, 
of  MedicalJurisprudence  and  Medical  Logic  in  the  University  of  Aber- 
deen, formerly  Assistant  to  the  Professor  of  Materia  Medica  in  the 
University  of  Edinburgh.  With  woodcuts  and  lithograph.  8vo.,  pp. 
201.  Edinburgh  :  Maclachlin  &  Stewart.  London  :  Simpkin  Marshall 
&  Co.,  1884. 

Tins  brilliant  illustration  of  what  inaugural  theses  may  be,  was  origi- 
nally presented  at  the  University  of  Edinburgh  for  the  doctorate,  and 
then  won  for  its  talented  author  a  gold  medal,  and  also  the  Goodsir  Memo- 
rial prize.  With  some  alterations  and  additions  it  was  subsequently  pub- 
lished in  the  Journal  of  Anatomy  and  Physiology,  and  is  now  reprinted 
in  book  form. 

Professor  Hay  adopts,  as-the  point  of  departure  for  his  well-conducted 
series  of  experiments  upon  rabbits,  cats,  dogs,  and  human  beings,  the 
question  whether  saline  purgatives  excite  a  flow  of  fluid  into  the  intes- 
tinal canal,  as  asserted  by  Liebig,  Rutherford,  Vulpian,  and  others,  or 
whether,  as  contended  by  Thiry  and  Radziejewski,  the  salt  merely  stimu- 
lates peristalsis.  These  observations,  one  hundred  and  twrenty-two  in 
number,  lead  our  author  to  conclude  that  saline  cathartics  do  provoke  an 
increase  of  secretion  within  the  alimentary  canal,  which  is  mainly  poured 
out  by  the  small  intestine,  little  or  none  being  contributed  by  the  stomach, 
liver,  and  pancreas  under  ordinary  circumstances.  This  fluid  is  very  similar 
to  the  normal  succus  entericus,  and  is  probably  supplied  in  great  part  by 
the  follicular  glands  of  the  intestinal  mucous  membrane.  Increased  peri- 
stalsis is  not  an  essential  factor  in  the  purgative  action  produced  by  a 
saline  cathartic. 

In  regard  to  the  effect  on  the  blood  and  circulation,  which  is  the  most 
important  question  from  a  practical  point  of  view,  Dr.  Hay  states  that  a 
saline  purgative,  by  exciting  profuse  intestinal  secretion,  removes  a  large 
amount  of  liquid  from  the  blood,  which,  if  the  salt  is  administered  in  con- 
centrated solution,  markedly  reduces  the  total  bulk  of  the  circulating  fluid. 
This  diminution  only  lasts  for  one  or  t  wo  hours,  as  the  blood  speedily  reim- 
burses itself  by  absorbing  fluid  from  the  tissues.  If  the  saline  cathartic 
is  given  in  dilute  solution  of  five  or  six  per  cent.,  aqueous  fluid  appears  to 
be  directly  absorbed  from  the  bowel  to  such  an  extent  that  no  concentra- 
No.  CLXXVIL— Jan.  1885.  16 


242 


Reviews  . 


[Jan. 


tion  of  blood  occurs.  Hence  the  effect  of  sulphate  of  soda,  for  example, 
dissolved  to  twenty  times  its  weight  of  water  upon  the  blood,  and  second- 
arily upon  the  tissue  fluids,  is  totally  different  from  that  produced  by  a 
twenty  per  cent,  solution  of  the  same  drug.  The  latter  form  of  adminis- 
tration is,  therefore,  strongly  indicated  in  the  treatment  of  many  forms  of 
dropsy,  when  it  is  desirable  to  obtain  a  rapid  and  powerful  reduction  of 
the  effused  fluid ;  and  our  author  assures  us  that  application  of  this  prin- 
ciple has  already  afforded  the  happiest  results  in  his  own  practice. 

J.  G.  R. 


Art.  XXXVIII. — Recent  Works  on  Ophthalmology. 

1.  The  Refraction  of  the  Eye.    A  Manual  for  Students.    By  Gus- 

tavus  Hartridge,  F.R.C.S.,  Assistant  Surgeon  to  the  Royal 
Westminster  Ophthalmic  Hospital.  8vo.,  pp.  204.  London:  J.  & 
A.  Churchill,  1884. 

2.  A  Treatise  on  Ophthalmology  for  the  General  Practitioner.  By 

Adolph  Alt,  M.D.  8vo.,  pp.  244.  St.  Louis  :  J.  H.  Chambers  & 
Co.,  1884. 

3.  The  General  Practitioner 's  Guide  to  Diseases  and  Injuries  of  the 

Eye  and  Eyelids.  By  Louis  H.  Tosswill,  B.A.,  M.B.  Cantab., 
M.R.C.S.,. Surgeon  to  the  West  of  England  Eye  Infirmary  at  Exe- 
ter.   8vo.,  pp.  147.    London  :  J.  &  A.  Churchill,  1884. 

1.  Such  a  flood  of  publications  has  in  the  last  few  years  been  let  loose 
upon  the  "  General  Practitioner"  for  his  enlightenment  on  the  various 
specialities,  particularly  ophthalmology,  that  he  need  scarcely  feel  hurt 
that  he  has  been  omitted  from  the  title  of  Mr.  Hartridge's  work.  Per- 
haps, after  all,  he  will  find  that  this  student's  manual  is  one  of  the  most 
useful  of  its  kind,  and  that  it  contains  all  that  is  absolutely  necessary  to 
guide  him  in  the  practical  clinical  work  which  alone  can  give  him  pro- 
ficiency in  this  branch  of  his  profession.  Without  this,  he  will  find  that 
"  studium"  is  little  better  than  "  somnium  ;"  and  that  he  may  sit  in  his 
office  and  diligently  read  all  the  guides  and  manuals  and  aids  that  pour 
from  the  press,  and  still  be  hopeless  of  fitting  himself  as  a  practical  "  refrac- 
tionist." 

The  first  chapter  deals  with  the  elementary  details  of  optics,  and  is 
very  concise  and  clear.  While  it  may  suggest  questions  to  the  mind  of 
the  advocate  of  a  high  standard  of  medical  education  in  regard  to  the 
character  of  the  preliminary  examinations  in  English  medical  schools, 
it  cannot  be  denied  that  it  may  prove  useful  to  a  considerable  number  of 
aspirants  for  ophthalmological  knowledge  on  this  side  of  the  ocean  at 
least. 

The  second  chapter  commences  with  a  brief  reference  to  the  cardinal 
points  in  the  refraction  of  the  eye,  which  must  be  utterly  unintelligible 
to  those  who  have  no  other  source  of  information.  As  the  reference  is 
too  brief  to  give  any  idea  of  the  significance  of  these  points,  as  little  or  no 
use  is  made  of  them  afterwards,  and  as  the  statement  that  the  "  two  prin- 
cipal focal  points  are  situated  close  together  in  the  anterior  chamber"  is 
incorrect  and  misleading,  this  part  of  the  chapter  might,  perhaps,  have 
been  omitted  without  diminishing  its  value.    The  rest  is  very  satisfactory 


1885.] 


Recent  Works  on  Ophthalmology. 


243 


and  gives  a  clear  demonstration,  well  illustrated  with  numerous  diagrams, 
of  the  different  kinds  of  refraction,  and  of  accommodation  and  convergence. 

The  methods  of  determining  the  errors  of  refraction  by  means  of  the 
ophthalmoscope,  by  the  indirect  and  direct  methods,  are  next  discussed ; 
and  then  comes  a  chapter  in  which  "  retinoscopy,"  which  is  evidently  a 
favorite  with  the  author,  is  treated  more  fully  than  any  other  subject. 
We  cannot  help  thinking  that  it  occupies  more  space  than  its  practical 
value  entitles  it  to.  Even  upon  the  showing  of  its  most  enthusiastic  ad- 
vocates, "  retinoscopy"  is  so  infinitely  inferior,  in  convenience  of  applica- 
tion and  accuracy  of  results,  to  the  direct  method,  that  it  is  questionable 
if  those  who  are  looking  only  for  aids  to  practical  work  will  be  repaid  for 
the  trouble  of  mastering  its  somewhat  complicated  details. 

The  means  of  detecting  and  correcting  the  different  forms  of  errors  of 
refraction  are  well  described,  but  we  were  rather  surprised  to  find  our 
old  familiar  acquaintance  of  nearly  twenty  years  standing,  Dr.  John 
Green's  clock-dial  astigmatic  test,  attributed  to  Dr.  Carter.  Perhaps 
this  test  is  now  so  nearly  of  age,  and  is  such  a  universal  favorite,  that  it 
can  scarcely  be  said  any  longer  to  belong  to  anybody ;  but  its  paternity  is 
unquestionable. 

2.  There  may  be  a  difference  of  opinion  as  to  whether  the  time  and 
labor  of  an  author  so  favorably  known  as  Dr.  Alt  are  best  employed  in 
adding  "  one  more  to  the  long  list  of  manuals  on  ophthalmology,  which 
the  last  few  years  have  produced."  But  his  work  has  been  well  done,  and 
his  book  may  be  said  to  differ,  in  some  respects,  from  the  other  members 
of  its  numerous  family.  It  is  intended  solely  for  the  general  practitioner  ; 
and  the  author  has  aimed  to  avoid  details  of  subjects  of  little  or  of  no  use 
to  him,  and  to  "  give  him  a  clear  idea  of  the  principles  of  ophthalmology, 
together  with  so  much  only  of  its  practice  as  he  might  be  reasonably  justi- 
fied in  attempting." 

It  is  doubtful,  however,  whether  this  very  desirable  kind  of  discretion 
can  be  safely  developed  by  an  entirely  superficial,  or  external,  knowledge  ; 
and  we  cannot  help  thinking  that  Dr.  Alt,  in  his  desire  to  withhold  from 
the  reader  "  such  information  as  would  be  likely  only  to  lure  him  into 
dangerous  paths,"  has  made  a  mistake  in  neglecting  the  ophthalmoscope. 
While  it  is  frequently  referred  to  as  a  means  of  diagnosis,  no  directions 
are  given  for  its  use.  The  time  has  gone  by  when  the  ophthalmoscope 
can  be  considered  the  private  property  of  specialists  ;  and  some  practical 
knowledge  of  its  use  must  form  a  part  of  the  equipment  of  every  good  "  all 
round  doctor"  of  the  future. 

One  of  the  best  chapters  is  the  first,  on  the  anatomy  of  the  eye.  We 
know  of  no  other  book  in  which  so  much  practical  information  upon  this 
subject  is  so  clearly  conveyed  in  so  small  a  space. 

The  numerous  glimpses  of  pathology,  scattered  through  the  other  chap- 
ters, will  be  found  very  useful  to  readers  who  have  not  at  hand  the  author's 
excellent  "  lectures  on  the  human  eye." 

The  text  is  well  printed,  and  is  liberally  illustrated  with  very  good  cuts. 

3.  Ophthalmological  condensation  has,  perhaps,  about  reached  its  limits 
in  Mr.  TosswilPs  little  work.  It  is  innocent  of  illustration,  refraction  and 
accommodation  are  entirely  ignored,  and  ophthalmoscopy  is  merely  re- 
ferred to  two  or  three  times  as  a  mystery  beyond  the  ken  of  the  general 
practitioner. 


244 


Reviews. 


[Jan. 


It  can  scarcely  be  said  to  fill  a  want  very  seriously  felt,  as  it  contains 
nothing  that  cannot  be  found  in  works  on  general  surgery. 

Perhaps  the  time  is  not  far  distant  when  no  man  with  an  enlightened 
conscience  will  think  it  safe  to  practise  medicine,  in  districts  remote  from 
specialists  and  hospitals,  until  a  few  visits  to  an  ophthalmic  clinic  have 
given  him  some  familiarity  at  least  with  the  external  diseases  of  the  eye. 
Those  who  have  not  enjoyed  this  advantage,  and  have  grown  "too  busy  to 
study"  before  they  have  prepared  themselves  for  their  work,  may  spend 
an  evening  profitably  in  reading  this  little  book.  It  is  well  written,  its  de- 
scriptions of  morbid  conditions  are  remarkably  accurate,  considering  their 
extreme  brevity,  and  the  directions  for  treatment  are  sound.    G.  C.  H. 


Art.  XXXIX  Elements  of  Practical  Medicine.  By  Alfred  H.  Car- 
ter, M.D.  Lond.,  Member  of  the  Royal  College  of  Physicians,  London ; 
Physician  to  the  Queen's  Hospital,  Birmingham  ;  Assistant  Physician 
to  the  Children's  Hospital,  Birmingham,  etc.    Second  edition.  Crown 

.  8vo.,  pp.  427.    London  :  H.  K.  Lewis,  1883. 

The  author  of  this  handy  little  volume  disclaims  any  attempt  to  com- 
pete with  the  larger  standard  works  upon  the  Practice  of  Medicine,  and 
declares  that  his  object  has  been  partly  to  provide  the  student  with  a 
general  introduction  to  the  study  of  medicine,  and  partly  to  bring  the 
essentials  of  the  subject,  as  far  as  required  for  the  ordinary  medical  qualifi- 
cations, within  the  grasp  of  those  who  are  not  disposed  or  have  not  the  leisure 
to  read  the  large  and  complete  works  referred  to  ;  a  class  of  readers  which 
Dr.  Carter  considers  usually  meets  with  too  little  sympathy.  As  a  com- 
pendium of  the  practice  of  medicine  the  book  is  entitled  to  a  high  rank ; 
and  the  fact  that  a  second  edition  has  been  called  for  in  less  than  three 
years  shows  that  in  London,  as  elsewhere,  there  are  a  great  many  students 
eagerly  seeking  a  guide  which  will  lead  them  along  a  royal  road  up  the 
toilsome  hill  of  learning.  If  those  who  use  aids  of  this  kind  would  always 
go  on  with  the  study  in  more  elaborate  systems  of  practice  of  physic,  no 
valid  objection  could  be  urged  against  the  "  Essentials"  and  "  Compen- 
diums"  so  popular  among  the  idler  pupils  of  every  medical  class  ;  but 
the  tendency  in  poor  humanity,  unless  impelled  by  that  rare  gift,  a  real  and 
unquenchable  thirst  for  the  acquisition  of  knowledge,  to  rest  satisfied  with 
knowing  just  enough  to  "  get  through"  is  naturally  so  powerful,  that  we 
doubt  the  propriety  of  encouraging  it  by  any  artificial  stimulus  of  this  type. 
Still  it  must  be  admitted  that  any  one  who  has  stored  away  in  his  memory 
all  the  contents  of  this  work  will  be  better  informed  respecting  diseases 
and  their  treatment  than  a  majority  of  the  practising  physicians  of  the  pre- 
sent day.  Being  fully  up  to  the  times,  and  containing  a  condensed  list  of 
prescriptions  found  useful  by  the  author  in  all  the  more  common  maladies, 
the  volume  on  account  of  its  convenient  size  might  be  of  great  service 
to  practitioners  in  rural  districts,  who  frequently  desire  to  glance  over  the 
opinions  of  a  recent  authority,  regarding  some  obscure  or  puzzling  case, 
whilst  actually  on  the  road  to  visit  it.  Under  these  circumstances  this 
excellent  little  work  of  Dr.  Carter's  may  prove  the  best  substitute  for  a 
consultation  with  some  famous  London  physician,  available,  and  as  such 
we  warmly  recommend  it  to  our  readers.  J.  G.  R. 


1885.] 


245 


QUARTERLY  SUMMARY 

OF  THE 

IMPROVEMENTS  AND  DISCOVERIES 

IN  THE 

MEDICAL  SCIENCES. 


ANATOMY  AND  PHYSIOLOGY. 

Experimental  Researches  on  the  Biliary  Secretion. 

Dr.  D.  Baldi  has  recently  undertaken  a  series  of  experiments  on  the  process 
of  secretion  of  the  bile  in  the  laboratory  of  M.  Luciani,  of  Florence,  in  which  he  has 
endeavored  to  ascertain  whether  it  takes  place  in  a  uniform  manner  in  accordance 
with  the  presence  or  absence  of  food  in  the  alimentary  canal,  and  whether  it  varies 
materially  with  the  nature  of  the  food.  The  results  are  given  in  the  third  volume 
of  the  Archives  Italiennes  de  Biologic  A  biliary  fistula  was  first  made,  the 
ductus  communis  choledochus  being  ligatured  so  that  no  bile  entered  the  duode- 
num. Dr.  Baldi  found  that  there  was  a  singular  irregularity  in  the  quantity  of 
the  secretion  formed,  distinguishing  the  function  of  the  liver  from  all  other 
digestive  secreting  organs.  Not  only  was  there  great  variation  in  the  absolute 
quantity  secreted,  but  the  composition  of  the  bile  differed  remarkably  at  different 
periods  after  a  meal.  Speaking  broadly,  in  an  animal  that  has  been  supplied 
with  food,  there  is  an  augmentation  in  the  total  quantity  of  bile  secreted  in  the 
course  of  some  hours,  as  compared  with  the  quantity  secreted  in  the  course  of 
some  hours,  as  compared  with  the  quantity  secreted  in  the  same  time  by  the  ani- 
mal when  fasting.  It  is  not  possible,  however,  to  fix  the  time  at  which  the  secre- 
tion of  bile  after  food  is  at  its  maximum  ;  indeed,  it  is  even  possible  that  the 
maximum  may  be  attained  during  some  one  hour  when  the  animal  is  fasting. 
Different  kinds  of  food,  starches,  proteids,  fats,  and  mixed  foods,  have  no  appre- 
ciable effect  on  the  quantity  or  quality  of  the  bile.  If  we  consider,  in  addition, 
that,  unlike  the  other  secretions  which  are  poured  into  the  intestinal  tract,  the 
bile  continues  to  be  secreted  in  prolonged  fasting,  as  has  been  demonstrated  by 
various  experiments,  we  shall  be  led  to  the  conclusion  that  this  fluid,  from  a 
physiological  point  of  view,  has  more  analogy  with  urine  than  with  the  other  di- 
gestive fluids.  In  a  second  series  of  researches,  in  which  the  effects  of  reputed 
cholagogue  drugs  were  investigated,  Dr.  Baldi  is  not  in  accord  with  either 
Rohrig  or  with  Rutherford.  Rohrkf  found  that  colocvnth  was  the  most  active 
cholagogue ;  then,  in  succession,  jalap,  aloes,  senna,  and  rhubarb.  Rutherford 
considered  the  order  to  be — podophyllin,  rhubarb,  aloes,  colocynth,  senna,  and 
other  drugs.  Baldi  experimented  with  podophyllin,  rhubarb,  jalap,  sodium, 
phosphate,  pilocarpine,  and  Carlsbad  water,  and  from  his  results,  feels  inclined  to 


246 


Progress  of  the  Medical  Sciences. 


[Jan. 


doubt  altogether  the  cholagogue  value  of  all  these  substances.  He  admits,  how- 
ever, that  the  presence  of  a  biliary  fistula  seriously  interferes  with  the  action  of 
remedies.  Dr.  Baldi  undertook  still  another  series  of  experiments,  to  determine 
whether  bile  injected  into  the  blood  was  excreted  by  the  liver.  The  animal  em- 
ployed was  a  dog.  The  bile  injected  was  that  of  the  ox,  deprived  of  mucus. 
Dog  bile  is  brown  ;  ox  bile  green.  Almost  immediately  after  the  injection  of  ox 
bile  the  color  of  the  bile  secreted  by  the  dog  became  green. — Lancet,  November 
29,  1884. 

Modifications  of  the  Blood  during  Pregnancy. 

Cohnstein,  in  an  article  on  this  subject  in  Pfluger's  Archiv,  Bd.  xxiv.,  Heft 
3  and  4,  1884,  says  that  up  to  the  present  time  authors  have  not  been  absolutely 
in  accord  as  to  the  modifications  which  take  place  in  the  blood  during  pregnancy. 
He  made  a  series  of  experiments  on  pregnant  and  non-pregnant  ewes,  using  the 
apparatus  of  Hayem  and  Malassez,  modified  by  Zeif.  In  the  pregnant  animals 
he  found  a  minimum  of  8,305,555,  a  maximum  of  10,300,000,  a  mean  of  9,742,222 
red  corpuscles  per  cubic  centimetre.  With  this  diminution  of  the  red  disks  in 
pregnant  animals,  we  would  naturally  expect  a  diminution  in  the  percentage  of 
hsemoglobine  ;  but  experiments  showed  that  such  was  not  the  case.  In  the  preg- 
nant animals  the  percentage  was  7.8;  in  non-pregnant,  5.5.  The  percentage, 
then,  is  larger  in  the  pregnant  state,  as  is  the  size  of  the  red  globules  ;  thus  the 
smaller  number  is  largely  compensated. — Archives  de  TocoL,  November,  1884. 


MATERIA  MEDICA  AND  THERAPEUTICS. 

Gastro-Intestinal  Therapeutics. 

In  a  recent  lecture  on  this  subject,  Prof.  Dujardin-Beaumetz  calls  atten- 
tion to  the  more  recent  gastro-intestinal  medications,  the  application  of  electricity 
to  the  treatment  of  affections  of  the  stomach  and  intestines,  enteroclism  and 
alimentary  enemata. 

The  application  of  electricity  to  the  treatment  of  gastro-intestinal  affections  is 
much  more  extensive  now  than  a  few  years  ago ;  it  may  be  studied  in  its  appli- 
cability to  diseases  of  the  stomach,  and  to  those  of  the  intestines.  In  persistent 
vomiting  and  in  acute  gastralgic  pains  it  is  used  by  Apostoli,  who  has  continued 
the  experiments  made  by  Prof.  Semmola  in  1861,  with  continuous  currents.  He 
used  in  these  cases  what  he  calls  positive  polar  galvanism  of  one  of  the  pneumo- 
gastrics.  It  is  carried  out  in  the  following  manner :  The  positive  electrode  is 
placed  external  to  the  sternal  end  of  the  clavicle,  on  a  level  with  the  upper  sur- 
face of  the  bone,  just  at  the  point  marked  by  the  depression  between  the  clavicu- 
lar insertions  of  the  sterno-mastoid  muscle.  This  electrode  is  made  of  a  piece  of 
carbon  covered  with  chamois  skin,  the  skin  being  moistened ;  the  other  electrode 
is  a  roller  which  the  patient  holds  in  his  hand.  A  continuous  current  is  then 
furnished  by  a  Gaiffe  or  Trouve  battery.  The  quantity  varies  between  five  and 
fifteen  milli-amperes,  and  should  be  such  that  the  epigastric  pain  disappears 
under  its  influence ;  the  current  being  continued  until  all  painful  or  spasmodic 
phenomena  disappear,  this  requiring  from  ten  to  twenty  minutes,  or  longer. 
For  vomiting,  Dr.  Apostoli  recommends  that  the  galvanism  be  commenced  while 
the  stomach  is  empty ;  the  patient  should  then  eat  something  during  the  galvani- 


1885.] 


Materia  Medica  and  Therapeutics. 


247 


zation,  which  is  kept  up  until  every  symptom  of  vomiting  has  disappeared. 
Dujardin-B eaumetz  has  often  used  this  method,  and  has  had  excellent  results  in 
some  cases,  especially  in  that  state  so  well  described  by  Lucien  Denian,  in  his 
These  on  gastric  hysteria.  The  procedure  is  not  dangerous,  is  not  complicated, 
and  may  be  used  without  any  inconvenience. 

Another  procedure,  which  requires  much  more  care,  is  the  internal  application 
of  electricity  to  the  stomach.  Fiirstner  and  Neflel,  Macaris  and  Bonnefin  have 
already  used  induced  and  feeble  intermittent  currents  for  causing  contractions 
of  the  stomach.  Perli,  in  1879,  used  the  induced  current  in  the  stomach, 
using  as  a  conductor  an  oesophageal  sound,  and  recommended  this  faradiza- 
tion in  the  treatment  of  dilatation  and  chronic  catarrh  of  the  stomach.  Bocci 
also,  in  1881,  repeated  the  experiments  of  Perli,  always  with  the  faradic 
current ;  and  Dr.  Bardet,  who  has  recently  written  an  excellent  book  on  medical 
electricity,  uses  the  continuous  current,  and  practises  direct  galvanization  of  the 
stomach.  The  instrument  used  by  him  consists  of  a  stomach  siphon,  in  which 
an  electrode,  terminating  in  a  carbon  olive-shaped  bulb,  is  carried  to  the  stomach. 
The  bulbous  end  of  the  electrode  never  passes  beyond  the  extremity  of  the 
sound,  and  should  not  come  directly  in  contact  with  the  mucous  membrane  of  the 
stomach.  The  sound  is  first  introduced  without  the  electrode,  and  then,  when  it 
was  fairly  passed  into  the  stomach,  the  electrode  is  passed  in.  A  funnel-tube 
being  connected  with  the  sound,  the  stomach  is  filled  with  water,  after  which  one 
electrode  is  placed  in  the  patient's  hand  or  on  his  stomach,  the  other  being  fixed 
to  the  upper  extremity  of  the  conductor  passing  into  the  stomach.  The  current 
used  in  these  cases  will,  of  course,  vary  according  to  the  indications  to  be  fulfilled ; 
in  cases  of  dilatation  of  the  stomach,  when  it  is  desired  to  cause  contractions  of 
the  muscular  coats,  the  negative  pole  should  be  introduced  into  the  stomach,  and 
the  slow,  interrupted  galvanic  current  used  ;  to  regulate  the  interruptions,  a 
Gaiffe's  metronome  is  used.  If  it  be  desired  to  control  vomiting,  the  positive 
pole  is  carried  into  the  stomach  and  only  continuous  currents  are  used.  But 
whether  the  positive  or  negative  pole  be  used  in  the  stomach,  it  is  always  through 
the  medium  of  the. water  that  the  current  acts  upon  the  walls  of  the  stomach. 
The  intensity  of  the  current  varies  from  fifteen  to  twenty  milli-amperes. 

Very  excellent  effects  have  been  obtained  in  cases  of  intestinal  occlusion  by 
internal  use  of  electricity.  First  used  in  1826,  by  Leroy  d'Etiolles,  under  the 
form  of  faradization,  it  has  given  excellent  results  in  the  treatment  of  internal 
strangulation,  notably  in  the  hands  of  Bucquoy,  in  1878  ;  and  still  more  recently 
Boudet  has  placed  the  method  on  a  sound  basis.  He  uses  galvanism,  having  a 
rectal  excitator  in  which  is  an  electrode  which  never  comes  in  contact  with  the 
intestinal  mucous  membrane.  The  negative  pole  should  be  introduced  into  the 
intestine,  the  positive  pole  being  placed  on  the  abdominal  wall.  The  current 
should  be  of  feeble  intensity,  not  more  than  ten  or  fifteen  milli-amperes.  The 
operator  should  be  careful,  from  time  to  time,  to  interrupt  the  continuous  current 
by  pressing  on  the  interrupter  of  the  apparatus.  There  should  be  from  three  to  four 
stances  a  day,  as  may  be  necessary,  and  each  one  should  last  twenty  or  thirty  min- 
utes. Dr.  Bardet  has  modified  the  rectal  excitator,  and  in  view  of  the  good  re- 
sults which  Dujardin-Beaumetz  has  obtained  with  Debove's  tube,  he  has  utilized 
the  same  for  intestinal  galvanization.  It  is  especially  in  cases  of  ileus  or  volvulus, 
or  in  the  pseudo-strangulations  due  to  paralysis  of  the  muscular  fibres  of  the  in- 
testine, that  electricity  gives  the  best  results,  though  it  is  absolutely  of  no  value 
in  cases  of  compression  of  the  intestine  by  tumors,  or  of  strangulation  by  perito- 
neal bands. 

In  cases  of  strangulation  by  compression  of  the  intestine  or  by  degeneration  of 
the  viscus,  we  may  employ  a  method  recommended  by  Cantani,  of  Naples,  to 


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-which  he  has  given  the  name  enteroclism.  The  apparatus  for  performing  entero- 
clism  is  extremely  simple,  and  consists  of  a  reservoir  furnished  with  a  plug  cor- 
responding to  a  caoutchouc  tube  with  a  canula,  which  is  carried  into  the  intestine, 
and  a  more  or  less  intense  current  is  set  up  in  the  gut  according  to  the  height  to 
which  the  reservoir  is  carried.  Cantani  has  shown  that  certain  bodies,  oil  among 
others,  may  be  made  to  penetrate  not  only  the  large  intestine,  but  even  into  the 
small,  and  so  far  up  that  the  oil  will  be  vomited.  He  applies  his  method  not 
only  to  strangulations,  but  also  to  the  dressing  of  affections  of  the  intestinal 
mucous  membrane ;  and  Dominicis,  Paolucci,  Pera,  Perli,  and  more  recently 
Muselli,  have  shown  that  this  method  has  great  advantages.  Dujardin-Beaumetz 
has  shown  that  the  Debove  tube  is  the  best  enterocliseur,  as  it  may  be  carried 
high  up  into  the  intestine  by  reason  of  its  suppleness  ;  and  by  the  aid  of  the  siphon 
the  intensity  of  the  current  may  be  varied  at  will.  The  tube  for  this  use  should 
have  an  aperture  relatively  small,  so  as  to  give  greater  force  to  the  jet.  The 
question  of  alimentary  enemata  is  now  quite  definitely  determined.  Albertoni, 
Garland,  Czerny,  and  others  have  shown  that  the  large  intestine  and  its  lower 
extremity  have  no  digestive  properties,  they  can  only  absorb.  It  is  necessary, 
therefore,  as  has  been  shown  by  Dujardin-Beaumetz  and  Chevalier,  that  the  ene- 
mata, to  be  nourishing,  should  contain  peptonized  substances,  and  this  is  one  of 
the  most  useful  applications  of  peptones.  The  peptones  now  on  the  market  are 
both  solid  and  liquid  ;  the  dry  are  much  to  be  preferred  to  the  liquid.  The 
enemata  should  be  carried  as  high  as  possible  into  the  intestine,  by  means  of  the 
Debove  tube  or  one  of  the  enterocliseurs.  The  rectum  should  always  be  thor- 
oughly washed  out  before  the  enema  is  administered.  The  composition  of  the 
clyster  should  be  about  as  follows  :  the  yolk  of  one  egg,  two  dessertspoonfuls  of 
dry  peptones,  five  drops  of  laudanum  ;  if  the  peptones  be  acid,  add  about  gr.  vij 
of  bicarbonate  of  soda.  If  liquid  peptones  be  used,  the  quantity  should  be  two 
tablespoonfuls  ;  and  the  enemata  are  given  morning  and  evening.  Catillon  and 
Darember  have  shown  that  this  method  of  feeding  may  be  continued  for  a  month 
without  irritating  the  rectum. — Bull.  Ge"nerale  de  The'rapeutique,  Nov.  15,  1884. 

The  Difference  in  the  Therapeutic  Effect  of  Electric  Currents,  and  the  Electro- 
Diagnostic  Exploration  of  the  Visual  Field. 

In  an  exhaustive  article  on  this  subject,  Dr.  C.  Engelskjox,  of  Christiania, 
draws  the  following  conclusions  :  — 

1.  Experiments  on  patients  suffering  from  vascular  neuroses  have  shown  that, 
in  the  local  application  to  the  skin  of  the  subject,  with  the  use  of  the  electric 
bath,  the  two  kinds  of  electric  current  exercise  an  inverse  effect  on  the  vessels  ; 
whilst  the  faradic  current  dilates  the  spasmodically  constricted  vessels,  the  gal- 
vanic current  constricts  the  actively  dilated  vessels.  In  conformity  with  this 
difference  in  action,  the  faradic  current  at  the  same  time  produces  an  increased, 
the  galvanic  a  lowered,  temperature.  There  seems  to  be  no  difference  as  to  the 
action  of  the  two  poles  of  the  galvanic  battery. 

2.  The  central  application  of  electricity  enables  one  to  see,  in  analogous  cases 
of  cutaneous  vascular  neuroses,  a  difference  in  effect  between  the  two  kinds  of 
current,  so  that,  in  certain  given  cases,  the  cure  may  only  be  due  to  one  of  them, 
either  the  faradic  or  the  galvanic. 

3.  Comparative  experiments  on  patients  suffering  from  hemicrania  and  other 
central  neuroses  have  also  shown  that  the  galvanic  current  acts  contrary  to  the 
faradic,  from  a  therapeutic  point  of  view  ;  whilst  only  one  of  the  currents,  the 
positive,  produces  a  cure  in  a  given  case,  the  other  (negative')  aggravates  the 
disease.    The  difference  in  the  effect  of  the  two  currents  on  the  subjective  symp- 


1885.] 


Materia  Medica  and  Therapeutics. 


249 


toms  is,  in  most  cases,  seen  instantly,  and  is  very  striking.  It  is  possible  to 
neutralize  the  effects  of  one  by  the  other. 

4.  As  in  the  central  neuroses,  electricity  acts  in  the  same  manner  as  in  hemi- 
crania,  so  that  in  certain  cases  the  galvanic  current  alone,  and  in  others  the  fara- 
dic  current  alone  exercises  a  happy  effect ;  whilst  the  treatment  by  the  negative 
current  has  an  injurious  action,  these  neuroses  appear,  in  analogy  with  hemicrania, 
to  be  of  a  dualistic  nature. 

5.  The  neurotic  diseases  of  the  ganglia  of  the  great  sympathetic,  such  as 
stenocardia,  cardialgia,  etc.,  behave,  as  regards  electric  currents,  in  the  same 
manner  as  diseases  of  the  central  nervous  system. 

6.  Engelskjon  has  also  seen  cases  certainly  related,  by  reason  of  their  symp- 
tomatology, to  diseases  accompanied  by  evident  anatomical  alterations  of  the 
central  organs,  and  which  do  not  behave  in  the  least  as  neuroses  with  electric 
currents,  though  they  are  promptly  cured  by  electric  treatment. 

7.  It  is  more  than  probable  that  the  peculiar  nature  of  the  etiological  factors 
exerts  a  determining  influence  on  the  future  form  of  a  particular  case,  and  that 
consequently  the  recognition  of  the  etiological  relations  in  a  given  case  enables 
us  to  make  a  choice  of  the  two  kinds  of  currents. 

8.  The  diseased  state  of  the  spinal  ganglia  may  act  in  a  reflex  manner  on  the 
spinal  cord,  and  give  rise  to  spinal  symptoms.  In  the  same  manner  the  diseased 
condition  of  the  cord  is,  as  is  well  known,  capable  of  exerting  a  reflex  action  on 
the  brain,  and  of  causing  cerebral  symptoms.  The  progress  of  the  reflex  action 
is  always  from  below  upwards.  In  this  connection  it  was  observed  that  the 
organ  secondarily  attacked  should  almost  always  be  treated  by  a  current  different 
from  that  used  on  the  organ  primarily  diseased. 

9.  Engelskjon  treated  cerebral  symptoms  by  electrization  of  the  medulla  oblon- 
gata, one  of  the  electrodes  being  placed  in  the  nuchal  fossa,  the  other  above  the 
larynx.  The  spinal  symptoms  may  be  treated  simply  by  conducting  the  current 
across  the  lower  part  of  the  cervical  portion  of  the  cord. 

10.  The  well-known  increase  of  the  morbid  symptoms,  caused  by  a  long  use 
of  electricity,  is  due  to  the  effect  of  the  current  on  the  healthy  ganglionic  cells. 

11.  Electrization  of  the  brain,  the  spinal  cord,  the  ganglia,  and  the  skin  exerts 
a  powerful  influence  on  the  functions  of  the  retina  ;  so  much,  that  in  certain 
given  cases,  the  positive  current  extends  the  visual  field,  and  often  increases,  at 
the  same  time,  the  activity  of  vision.  As  these  effects  may  be  said  to  be  direct, 
we  may  use  electricity  in  exploring  the  visual  field. 

12.  If  one  will  submit  his  hands  and  forearms  to  the  action  of  warm  or  cold 
water  for  a  few  minutes,  the  cold  water  will  be  found  to  produce,  in  special  cases, 
the  same  effect  on  the  visual  field  as  the  galvanic  current ,  whilst  the  effect  of 
warm  water  is  the  same  as  that  of  the  induced  current. 

13.  In  this  general  action  on  the  skin,  cold  and  warm  water  exert,  in  such 
cases  of  a  given  disease,  the  same  therapeutic  effects  as  the  galvanic  and  the 
faradic  currents  employed  separately.  The  effects  of  cold  water  are  similar  to 
those  of  galvanism,  those  of  warm  water  to  those  of  the  induction  current.  If 
one  will  only  recognize  the  kind  of  current  suited  to  a  special  case,  he  is  in  a 
position  to  indicate  the  proper  balneo-therapeutic  treatment.  And  conversely, 
the  good  or  bad  effects  of  cold  or  warm  water  will  serve  to  indicate  the  proper 
electric  treatment. 

14.  There  are  cases  of  nervous  disease  which,  though  generally  amenable  to 
electric  treatment,  can  only  be  cured  by  central  electrization,  and  grow  worse 
under  the  influence  of  one  or  the  other  of  the  two  kinds  of  currents.  It  is 
sometimes  possible  to  cure  certain  cases  in  another  manner,  by  electrization  of 
the  skin.    Used  in  this  way,  electricity  seems  to  act  in  two  different  ways  :  1,  by 


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Progress  of  the  Medical  Sciences. 


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acting  on  the  skin  itself ;  2,  by  acting  on  the  peripheral  nerves.  The  two  kinds 
of  currents  act  inversely  in  the  first  case,  though  not  in  the  second. 

15.  In  using  the  two  kinds  of  currents  on  the  peripheral  nervous  circuits  in 
cases  of  neuralgia,  Engelskjon  has  never  seen  any  qualitative  difference  in  their 
therapeutic  activity. — Nordiskt  Medicinskt  Arkiv,  Bd.  xvi.,  Hft.  4. 

Double  or  Bipolar  Uterine  Faradization. 

In  V  Union  M6dicale  for  October  28  and  November  1,  1884,  Dr.  G. 
Apostoli  has  an  article  on  this  subject,  the  first  portion  of  his  article  being 
mainly  concerned  with  his  theories  as  to  the  value  and  applicability  of  bipolar 
faradization  of  the  uterus,  the  following  being  a  summary  of  the  reasons  why  it  is 
preferable  to  the  unipolar  method  :  (1)  The  cutaneous  pole  is  suppressed,  and 
the  uterus  gets  the  full  benefit  of  the  whole  electric  current.  (2)  The  operation 
is  much  more  easily  performed,  requiring  no  assistant.  (3)  The  pain  is  lessened 
by  the  removal  of  all  electric  influence  from  the  cutaneous  surface.  (4)  Gen- 
eralization is  more  easy  by  this  method,  by  reason  of  the  ease  with  which  it  is 
carried  out,  and  hence  the  execution  is  more  complete.  (5)  It  is  by  far  more 
efficacious,  possibly  on  account  of  the  increase  of  the  uterine  contractility  and 
the  use  of  a  stronger  current,  more  intense  and  more  active  ;  is  therefore  much 
easier  and  less  harmful.1 

Clinical  experience  has  fully  justified  the  theoretical  claims  for  this  method. 
Patients  upon  whom  both  methods  have  been  used  much  prefer  the  bipolar  appli- 
cation ;  and,  contrary  to  what  is  seen  with  the  unipolar  method,  the  pain  is  of 
little  moment,  and  it  actually  appears  to  be  beneficial  in  cases  of  metritis. 

The  difference  between  the  contraction  of  smooth  and  striated  muscular  fibres 
is  well  known ;  one  is  active  and  immediate,  the  other  often  slow  and  sluggish. 
The  contractions  of  the  non-gravid  uterus  have  given  rise  to  much  discussion  and 
contradiction.  The  variability  of  the  contraction  from  the  point  of  view  of  time 
and  intensity  is  indisputable  ;  in  one  woman  several  minutes  may  elapse  before  it 
occurs,  in  another  it  takes  place  almost  immediately.  The  same  difference  is 
seen  as  regards  force  and  intensity.  This  is  a  clinical  fact.  Experiments  on 
animals  have  demonstrated  another  important  fact,  that  this  contraction  rarely 
takes  place  en  masse  in  striated  muscular  fibres ;  it  takes  place  progressively, 
being  first  localized  at  the  point  of  application  of  the  electricity,  and  then  radiates 
more  or  less  rapidly,  according  to  the  intensity  of  the  current,  through  the  whole 
organ.  Can  we  not  conclude,  from  this  fact,  that  in  the  woman  an  increase  in 
the  number  of  points  of  application  will  increase  the  action  of  the  electric  current, 
and  that  by  placing  both  poles  in  the  uterus  the  maximum  action  will  be  obtained 
from  any  given  current  ?  Clinical  experience  also  justifies  this  conclusion  as  re- 
gards the  human  subject ;  the  procedure  is  less  painful  and  more  active. 

As  regards  the  pain,  it  should  be  noted  there  is  a  marked  difference  in  electric 
sensibility  between  the  body  and  cervix  of  the  uterus  ;  a  fact  not  hitherto  pointed 
out.  The  cervix  is  by  far  the  more  sensitive  of  the  two  portions  ;  and  to  ob- 
tain the  minimum  amount  of  pain  with  the  maximum  effect,  the  electric  sound 
should  be  carried  completely  into  the  cavity  of  the  uterus.  In  this  way  the  inten- 
sity of  the  current  may  be  twice  as  great  as  by  the  unipolar  method.  In  Tripier's 
procedure  (the  unipolar)  the  medium  quantity  of  faradization  is  the  induction 
obtained  by  the  sheathing  of  half  the  bobbin  of  his  apparatus.  A  woman  will 
very  rarely  support  the  maximum,  and  here  we  must  understand  always  the 
maximum  of  the  bobbin  with  a  large  short  thread  or  the  quantity  current,  the 


1  Cuts  of  the  instrument  may  be  seen  in  L 'Union  3I$dicale,  No.  153,  Oct.  28,  1884. 


1885.] 


Materia  Medica  and  Therapeutic 


251 


onlv  one  used  in  the  treatment  of  metritis.  The  indications  for  and  tolerance 
of  the  fine  thread  bobbin  are  entirely  different.  In  Apostoli's  method  the  inverse 
is  true ;  the  maximum  is  often  obtained,  and  it  is  only  rarely,  especially  when 
the  sound  is  in  contact  with  both  the  cervix  and  body  of  the  uterus,  that  a 
medium  current  is  sufficient. 

Should  we  increase  the  intensity  of  the  current  and  force  the  quantity  of  the 
induced  current  ?  It  may  be  answered  that,  if  uterine  faradization  has  failed  in 
the  cure  of  metritis,  it  is  because  the  current  was  too  feeble.  To  increase  the 
action  Apostoli  has  made  several  models  of  his  electric  sound,  of  different  sizes 
and  with  the  poles  at  varying  distances  apart.  With  this  instrument  even  preg- 
nancy is  not  a  contraindication  to  the  use  of  electricity.  Very  great  care  must  be 
given  to  the  position  of  the  sound  in  case  of  pregnancy.  It  should  not  be  carried 
beyond  the  internal  os,  but  should  be  left  in  the  cervix,  and  held  there  firmly 
with  the  hand,  the  index  finger  being  in  the  vagina  and  against  the  posterior  lip 
of  the  cervix.  In  some  cases  of  very  pronounced  flexion,  when  the  uterus  is  in 
an  inflamed  state  and  every  movement  is  painful,  it  is  prudent  not  to  attempt  to 
carry  the  sound  into  the  uterine  cavity.  The  general  and  absolute  rule  is  that 
no  violent  movement  of  any  kind  may  be  made;  faradization  in  these  cases  is 
only  a  sort  of  therapeutic  hysterometre,  and  will  give  no  good  results  if  violence 
be  used. 

The  sound  should  always  be  introduced  without  the  speculum,  and  carried 
along  the  palmar  surface  of  the  index  finger,  should  be  carried  in  slowly,  without 
ejff'oi't,  and  arrested  as  soon  as  it  comes  in  contact  with  any  obstacle.  In  the 
treatment  of  metritis,  and  in  the  many  indications  after  parturition,  there  is  a 
large  field  of  usefulness  for  the  bipolar  method. — L' Union  Me'd.,  Oct.  28  and 
Nov.  1,  1884. 

Electro-Therapeutics . 

Dr.  A.  Hughes  Bennett,  in  an  introduction  to  a  discussion  on  this  subject  in 
the  Section  of  Pharmacology  and  Therapeutics  at  the  fifty-second  Annual  Meet- 
ing of  the  British  Medical  Association,  enumerates  some  of  the  chief  morbid 
conditions  for  the  treatment  of  which  electricity  is  believed  to  be  specially  suitable. 
These,  for  practical  purposes,  maybe  considered  under  three  classes  :  (1)  diseases 
characterized  by  diminished  functional  activity  ;  (2)  those  by  increased  functional 
activity ;  and  (3)  a  large  and  miscellaneous  collection  of  affections  associated 
with  local  and  general  malnutrition.  Under  the  first  heading  may  be  placed  para- 
lysis, anaesthesia,  atrophy,  sclerosis,  and  a  variety  of  other  morbid  states.  The 
etiology  of  these  conditions  is  often  obscure.  The  indication  for  their  treatment 
is  to  excite  and  stimulate,  to  exalt  functional  activity,  to  remove  anything  which 
inhibits  conduction,  to  overcome  obstruction,  and  to  modify  abnormal  nutrition- 
changes.  The  casual  as  well  as  the  symptomatic  manifestations  must  be  brought 
under  the  influence  of  the  current ;  and,  in  paralysis  or  anaesthesia,  not  only 
must  the  secondary  local  effects  be  treated,  but  the  primary  central  lesions  which 
caused  them  must  be  beneficially  modified.  Should  any  obstruction  to  natural 
impulses  exist  at  any  portion  of  the  nerve-tract,  this  may  often  be  successfully 
overcome  by  an  electric  stimulus,  which  thus  artificially  paves  the  way  for  subse- 
quent normal  impressions,  and  the  consequent  repetition  of  which  ultimately  ends 
in  the  transmissions  of  the  healthy  functions.  Here,  also,  attempts  are  made  to 
stimulate  depressed  functions  into  normal  activity;  and,  by  utilizing  the  catalytic 
properties  of  the  current,  in  modifying  nutrition,  and  influencing  the  trophic 
elements  of  the  tissues,  to  facilitate  the  absorption  of  morbid  products,  and  to 
promote  the  return  of  healthy  structure.    On  these  principles,  there  is  obviously 


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a  large  series  of  symptoms  and  diseases  capable  of  being  rationally  submitted  to 
the  electric  current,  and  it  is  probable  that  many  of  them  receive  more  benefit 
from  this  method  of  treatment  than  from  any  other. 

In  the  class  of  disorders  characterized  by  excessive  functional  activity,  there 
are  pain,  spasm,  contracture,  and  their  allied  affections.  Here,  also,  we  are 
generally  ignorant  of  the  seat  and  nature  of  the  primary  lesion  ;  but  we  assume 
the  symptoms  to  be  due  to  some  molecular,  or,  so-called,  functional  derangement, 
the  objective  existence  of  which,  however,  we  are  unable  to  demonstrate.  But, 
whatever  may  be  the  cause,  the  special  property  of  the  electric  current,  applied 
in  a  certain  manner,  is  to  relieve  motor  and  sensory  superexcitability,  not  only 
at  the  time  of  application,  but  often  permanently  afterwards  ;  and,  if  this 
influence  be  maintained,  the  nutrition  is  so  modified  as  to  result  in  the  entire 
removal  of  the  disease  itself.  These  sedative  and  alterative'  effects  of  the  electric 
current  obviously  suggest  its  employment  in  a  vast  variety  of  morbid  conditions. 

Finally,  the  tonic,  modifying,  or  catalytic  actions  of  electricity  may  be  em- 
ployed in  many  local  and  general  diseases.  As  has  been  already  stated,  the  effects 
are  supposed  to  be  due  to  the  influence  the  current  exercises  on  the  nutrition  of 
the  tissues,  the  modification  of  the  trophic  functions,  the  alteration  in  the  circu- 
lation, and  the  stimulation  of  the  absorptive  processes.  Of  the  exact  nature  of 
these  actions  we  know  nothing,  and  we  are  equally  ignorant  of  the  precise  patho- 
logical conditions  for  which  they  are  applied ;  and  practical  experience  alone 
indicates  their  utility.  Hence  electricity  has,  with  advantage,  been  employed  in 
local  ailments,  as  in  rheumatism,  gout,  joint- affections,  skin-diseases,  chronic 
inflammations,  and  so  on.  So,  also,  in  more  general  maladies,  on  the  same  prin- 
ciples, it  has  been  found  beneficial,  as  in  hysteria,  neurasthenia,  chorea,  general 
debility,  and  a  variety  of  other  miscellaneous  constitutional  disorders.  It  is 
especially  among  the  neuroses,  and  so-called  functional  derangements,  in  other 
words,  in  those  diseases  characterized  by  much  suffering  and  distress,  without 
demonstrable  tissue-change  to  account  for  them,  that  the  greatest  triumphs  of 
electrical  treatment  are  to  be  found. 

Although  these  are  the  general  conclusions  which  have  been  arrived  at  as  to 
the  utility  of  electricity  as  a  therapeutic  agent,  much  yet  remains  to  be  accom- 
plished in  this  direction,  and  a  vast  field  for  future  research  and  discovery  still 
lies  open  for  cultivation.  For  the  solution  of  the  complex  problems  involved, 
an  accumulation  of  facts,  observed  and  recorded  with  the  most  rigid  accuracy  and 
impartiality,  is  demanded.  Instead  of  electro-therapeutic  investigations  being 
conducted,  as  is  too  frequently  the  case,  by  those  ignorant  of  the  elements  of  the 
science,  and  registered  by  them  in  an  imperfect,  illogical,  and  unscientific  manner, 
the  question  requires  for  its  truthful  elucidation  an  extensive  technical  knowl- 
edge, dexterity  and  precision  in  the  management  and  recording  of  details,  and 
the  absence  of  prejudicial  opinions  or  interested  motives.  Doubtless,  any  one 
adopting  this  line  of  inquiry  in  such  a  scientific  spirit  would  be  rewarded  by  novel 
and  important  results. — Brit.  Med.  Journ.,  Nov.  22,  1884. 


MEDICINE. 

Examination  of  the  Blood  for  the  Diagnosis  of  Acute  Diseases. 
In  a  communication  to  the  Societe  Franchise  pour  1' Advancement  de  la 
Science,  M.  Hayem  says  that  most  valuable  work  has  been  done  in  the  past 


1885.] 


Medicine. 


253 


few  years  in  the  examination  of  the'  blood  as  a  means  of  diagnosis  of  acute 
diseases ;  this  study  has  only  been  made,  however,  by  chemical  procedures,  and 
there  is  still  wanting  a  practical  method  for  exact  diagnosis.  There  is  in  general 
pathology  a  vast  field  for  what  may  be  called  the  "  Semeiology  of  the  blood  as 
regards  the  prognosis  and  diagnosis  of  diseases."  Microscopic  examination  of 
the  blood  is  difficult,  on  account  of  the  excessive  vulnerability  of  its  elements  ; 
desiccation  and  evaporation  change  their  form,  and  interfere  with  their  exami- 
nation. 

Hayem  has  made  an  instrument  which,  notwithstanding  its  simplicity,  has  not 
been  used  by  physicians,  though  he  has  used  it  for  two  years.  He  has  made 
a  small  central  disk  in  a  plate  of  glass,  by  hollowing  out  a  circular  trench  three 
millimetres  in  diameter.  After  having  plastered  vaseline  on  the  part  of  the  plate 
immediately  outside  of  the  trench,  a  drop  of  blood  is  placed  on  the  disk  and  a 
small  plate  is  placed  over  it  and  fixed.  The  drop  of  blood  spreads  uniformly 
under  the  plate  and  makes  a  layer  of  some  thickness  under  the  little  disk,  com- 
pletely protected  from  evaporation  and  from  the  air.  After  having  acquired  a 
certain  skill  in  this  method,  one  makes  all  the  preparations  alike.  This  pro- 
cedure has  an  immense  advantage  in  showing  the  blood  as  it  is  in  the  vessels ;  the 
process  of  coagulation  may  be  studied  with  the  microscope,  and  the  quantity  of 
fibrin  in  the  blood  is  easily  appreciated.  When  normal  blood  is  examined  in 
this  way  it  seems  to  contain  only  a  very  few  and  very  short  filaments  of  fibrin  ; 
in  pathological  cases  it  contains  a  thick  fibrinous  reticulum  under  certain  circum- 
stances. The  amount  of  fibrin  may  be  measured  from  the  beginning  to  the  end 
of  a  disease.  Take,  for  example,  an  acute  febrile  disease,  at  its  onset ;  at  this 
time  the  diagnosis  is  difficult,  but  if  there  is  not  an  abundant  reticulum  of  fibrin 
one  may  almost  certainly  diagnosticate  a  pyrexial  disease.  This  method  is  very 
useful  in  facilitating  the  diagnosis  in  difficult  cases,  as,  for  example,  certain 
anomalous  forms  of  intermittent  fever.  Suppose  now  that  a  patient  gives  general 
evidences  of  pyrexia  at  the  beginning ;  if  there  is  no  fibrinous  reticulum,  the  case 
is  almost  certainly  one  of  typhoid  fever ;  if  the  reticulum  is  thick  typhoid  fever 
may  be  thrown  out  of  the  diagnosis,  as  may  such  inflammatory  complications  as 
pneumonia  or  pleurisy.  There  is  an  affection  which  so  closely  resembles  typhoid 
fever  that  it  is  often  mistaken  for  it ;  mucous  fever,  gastric  fever,  or  inflammatory 
fever,  as  it  is  called.  In  these  cases  there  is  a  constant  increase  in  the  amount 
of  fibrin  in  the  blood,  contrary  to  what  is  seen  in  typhoid  fever.  There  are  a 
certain  number  of  exceptions ;  some  of  the  inflammatory  diseases  of  the  phleg- 
masia are  not  attended  by  an  increase  in  the  amount  of  fibrin.  Such  are  certain 
forms  of  pneumonia,  as  what  has  been  called  typhoid  pneumonia,  pneumo-typhus. 
If  there  is  a  slight  reticulum  of  fibrin,  somewhat  greater  than  the  normal,  it  is 
no  longer  a  typhoid  pneumonia,  but  a  tuberculous  pneumonia,  a  caseous  lobar 
pneumonia.  The  phlegmasia,  the  types  of  which  are  gout,  rheumatism,  and 
frank  pneumonia,  may  be  always  recognized  by  their  augmentation  of  fibrin,  even 
in  the  apyretic  forms  of  gout  and  rheumatism. — Revue  Med.  Frang.  et  Eirang., 
Nov.  1,  1884. 

Pernicious  Ancemia  in  a  Child  Five  Years  Old. 

Dr.  Adolphe  Kjellberg  opens  a  paper  in  which  he  gives  the  history  of  this 
case,  by  stating  that  pernicious  anaemia  is  of  greater  extent  than  was  believed  at 
the  time  when  Biermer  called  attention  to  it  by  his  description  of  the  disease  ; 
that  it  is  chiefly  seen  at  mature  age  ;  that  it  runs  even  up  to  the  period  of  old  age  : 
but  that,  so  far  as  childhood  is  concerned,  only  one  case  has  been  thus  far  re- 
ported— that  of  a  child  11  years  old,  by  Quincke.    After  having  mentioned  the 


254 


Progress  of  the  Medical  Sciences. 


[Jan. 


principal  symptoms  of  this  case,  Kjellberg  gives  the  history  of  a  case  which  came 
under  his  own  care,  the  patient  being  only  5  years  of  age.  It  was  especially 
remarkable  for  its  rapid  course,  and  very  characteristic  symptoms,  such  as  dis- 
coloration of  the  skin,  which  became  of  a  yellowish  waxy  color,  pallor  of  the 
lips,  great  prostration,  asthma  on  the  least  exertion,  palpitations,  intense  anaemic 
bruit,  retinal  hemorrhages,  watery-looking  blood,  and  reduction  of  the  number  of 
red  disks  to  0.571  million  per  cubic  millimetre.  The  post-mortem  appearances 
were  also  very  characteristic  ;  extensive  fatty  degeneration  of  muscular  structure 
of  the  heart,  excessive  pallor  of  the  cerebral  substance,  hemorrhages  of  the  cere- 
bellum, pericardium,  pleura,  lungs,  and  peritoneum,  and  fatty  degeneration  of 
the  epithelium  of  the  renal  tubules. 

From  the  knowledge  gained  from  Quincke's  case  and  his  own,  Kjellberg  con- 
cludes that  pernicious  anaemia  presents  the  same  symptomatology  in  childhood  as 
in  adult  life. 

This  case  throws  but  little  light  on  the  etiology  of  pernicious  anaemia ;  and 
gives  no  ground  for  the  hypothesis  that  this  disease  is  the  result  of  a  life  of  priva- 
tion and  of  insufficient  nutrition,  for  this  child  was  in  comparatively  good  circum- 
stances. Kjellberg  is  rather  inclined  to  indorse  the  opinion  of  Warfringe  that 
pernicious  anaemia  should  be  considered  as  an  infectious  disease.  His  patient 
was  put  on  arsenic,  with  nourishing  food,  but  with  no  noticeable  result. — Nor- 
diskt  Medicinskt  Arkiv,  Bd.  xvi.  Hft.  13. 

The  Nature  of  Fever,  and  the. Cold- Water  Treatment  of  Fever. 
B.  Xaunyn  has  recently  contributed  an  article  on  this  subject  to  the  Archiv 
fur  Ezperim.  Pathol,  und  Pharmacie,  Bd.  xviii.,  Hft.  1  u.  2.  In  this  article 
he  calls  especial  attention  to  the  experiments  of  Liebermeister  and  Jurgensen, 
which,  in  spite  of  their  one-sided  character,  have  received  very  general  recogni- 
tion. Naunyn  draws  a  sharp  line  of  separation  in  fever  as  to  the  danger  of  in- 
creased temperature,  and  the  severity  of  the  disease  causing  it,  of  which  fever  is 
only  a  symptom.  He  has  experimentally  studied  the  dangers  of  over-heating 
the  organism,  where  there  is  no  general  disease,  by  placing  rabbits  in  a  specially 
constructed  apparatus.  The  result  of  these  experiments  was  that  completely 
healthy  normal  rabbits  bore  a  temperature  of  107.6°  Fahr.  for  from  one  day  to 
one  week,  and  for  the  most  part  without  injury  ;  but  that  a  temperature  of 
108.5°  or  109.4°  Fahr.  was  dangerous  and  fatal.  He  leaves  out  of  his  discus- 
sion, insolation  and  intense  hyperpyrexia,  for  which  he  advises  prompt  treatment 
with  cold  water. 

In  discussing  the  febrile  diseases,  pneumonia,  typhoid  fever,  relapsing  fever, 
scarlatina,  etc.,  he  concludes  that  the  high  temperature  is  absolutely  of  no 
moment  as  an  element  of  danger.  A  very  clear  example  is  seen  in  relapsing 
fever  in  which,  as  is  well  known,  high  temperature  is  the  rule,  reaching  a  degree 
seldom  seen  in  other  diseases,  and  which  may  persist  for  a  long  time  without  in- 
jury to  the  patient,  but  not  usually  considered  dangerous  by  physicians.  So  also 
in  typhoid  fever  in  which  low  temperatures  are  observed  (seldom  over  102.2° 
Fahr.),  but  which  are  accompanied  by  severe  general  disturbances,  the  patient 
recovering  more  slowly  and  with  more  difficulty  than  from  cases  which  are  simi- 
lar except  as  regards  the  presence  of  higher  temperature.  The  same  is  seen  in 
other  acute  febrile  diseases.  Naunyn  thinks,  therefore,  that  observations  as  to 
the  temperature  in  febrile  diseases  are  of  more  importance  as  a  rule  than  of  any 
other  single  symptom,  especially  since  we  have  no  such  certain  means  of  measur- 
ing other  symptoms  as  by  the  thermometer  in  abnormal  temperature. 

Naunyn  cannot  regard  Liebermeister' s  definition  of  temperature  as  correct. 


1885.J 


Medicine. 


255 


We  have  no  right,  he  thinks,  to  regardi  the  functional  disturbances  which  take 
place  in  single  organs  during  fever,  as  the  consequence  of  the  fever.  Fever  is  a 
symptom,  with  which  the  other  pathological  phenomena,  as  disturbances  of  the 
nervous  system,  of  the  circulatory  apparatus  and  of  nutritive  changes,  occur  as 
coordinate  symptoms,  and  the  occurrence  of  all  these  single  symptoms  is  the 
acute  affection. 

He  has  also  made  extensive  researches  in  the  acute  infectious  diseases  as  to 
the  nutritive  changes,  the  changes  of  the  blood  in  fever,  the  circulatory  disturb- 
ances, and  those  of  the  organs  of  secretion.  In  these  he  was  assisted  by  Dr. 
Minkowski,  who,  in  examining  the  blood  of  fevered  dogs,  found  no  constant 
chances  in  the  blood  disks.  But  he  found  in  the  same  blood  an  abnormal  acid — 
fermentable  lactic  acid.  Naunyn  also  made  experiments  on  the  excretion  ot 
urine  and  on  the  occasional  presence  of  carbonate  of  ammonium  in  fevered  per- 
sons. In  one  case  of  petechial  typhus,  he  found,  on  the  second  day  after  the 
crisis,  ninety-one  grams  of  urea,  and  in  a  second  case,  on  the  third  and  fourth 
days  after  the  commencement  of  the  fever,  one  hundred  and  sixty  grams. 
Nothing  conclusive  was  found  as  to  the  presence  of  carbonate  of  ammonia  in  the 
blood. 

After  discussing  the  nature  of  the  febrile  process,  Naunyn  develops  the  grounds 
upon  which  he  recommends  the  hydriatic  treatment  of  fever,  and  the  rules  by 
which  one  should  be  guided.  He  restricts  the  cold-water  treatment  (except  in 
cases  of  insolation  and  intense  hyperpyrexia)  entirely  to  typhoid  fever,  as  statis- 
tics have  not  yet  shown  that  it  has  a  favorable  influence  upon  the  course  of  other 
acute  febrile  diseases.  But  other  antipyretics,  as  salicylate  of  soda  and  quinine, 
never  act  so  well  in  typhoid  fever  as  the  cold-water  treatment.  The  rules  which 
he  gives  for  this'treatment,  in  the  course  of  typhoid  fever,  are  mainly  as  follows: 
He  prescribes  complete  baths  only,  dividing  them  into:  1,  cold  baths,  between 
72.5°  and  81.5°  Fahr.  ;  2,  lukewarm,  between  81.5°  and  90.5°  Fahr.  ;  3,  warm 
baths,  between  90.5°  and  95°  Fahr.  Typhoid  fever  patients  should  be  placed  in 
the  bath,  as  a  rule,  as  soon  as  the  temperature  in  the  axilla  reaches  103.1° 
Fahr.  The  frequency  of  the  baths  should  depend  upon  the  temperature  of  the 
patient.  The  temperature  should  be  taken  every  three  hours,  and  a  bath 
given.  Baths  of  77°  Fahr.  are  most  frequently  used  at  first,  and  then  of  83.2° 
or  86°  Fahr.,  but  never  under  72.5°.  The  patients  should  be  bathed  at  night 
as  well  as  during  the  day.  The  cold  bath  should  last  from  five  to  ten  minutes, 
the  lukewarm  from  ten  to  fifteen,  according  to  the  susceptibility  of  the  patient. 
After  the  bath  warm  wine  or  grog  should  be  given.  If  baths  at  these  tempera- 
tures have  no  favorable  effect,  and  the  patient  cannot  be  warmed  and  shows 
symptoms  of  collapse,  the  bath  should  be  4°  or  5°  higher.  If  the  temperature 
does  not  fall  sufficiently  with  baths  at  this  temperature,  or  if  it  soon  rises  again 
after  the  bath,  the  water  may  be  made  somewhat  cooler,  or  the  patient  may  be 
bathed  oftener,  and  before  the  temperature  reaches  103.1°  Fahr. 

In  severe  cases  of  typhoid  fever,  with  low  temperature  and  pronounced  gene- 
ral symptoms,  the  patient  may  be  bathed  with  advantage  if  the  axillary  tempera- 
ture reaches  102.2°.  In  some  cases  also,  cases  of  violent  delirium,  warm  baths 
may  be  given  between  the  cold  ones,  generally  in  the  afternoon  between  6  and  8 
P.  M.  The  influence  of  these  warm  baths  is,  as  a  rule,  very  good.  In  connec- 
tion with  the  bath-treatment,  Naunyn  places  great  reliance  upon  a  careful  dietary 
regimen. —  Centralb.  fur  klin.  Med.,  Sept.  13,  1884. 

An  Analysis  of  Cases  of  Diphtheria. 
At  a  recent  meeting  of  the  Berlin  Medical  Society,  Dr.  Henoch  read  a  paper 
on  diphtheria,  as  observed  in  the  Charite  Hospital  in  the  years  1882  and  1883, 


256  Progress  of  the  Medical  Sciences.  [Jan. 

the  full  text  of  which  is  to  be  published  in  the  next  "  Charite-Annalen."  Ex- 
clusive of  doubtful  cases  of  angina,  so-called  scarlatinal  diphtheria,  and  idiopathic 
croup,  no  fewer  than  319  cases  of  the  disease  were  observed  ;  216  of  these  were 
between  the  ages  of  two  and  six  years.  The  mortality  was  very  high — viz., 
208 — particularly  in  the  first  three  years  of  life,  for  only  17  out  of  118  attacked 
in  this  period  recovered.  This  high  mortality  was  ascribed  partly  to  the  "genius 
epidemicus,"  partly  to  the  unsanitary  surroundings  of  the  sick,  and  to  the  fact 
that  many  of  them  were  tuberculous  and  of  the  lowest  class.  In  145  cases  the 
larynx  was  implicated,  and  129  of  these  succumbed;  of  the  remaining  174  cases, 
79  died.  Tracheotomy  was  performed  in  138  cases,  with  only  16  recoveries — 
i.  e.,  11^  per  cent.  ;  but  17  of  these  deaths  were  due  to  the  supervention  of 
scarlet  fever.  Of  66  cases  tracheotomized  in  the  first  three  years  of  life  only  2 
survived ;  death  being  almost  invariably  due  to  croupous  bronchitis  or  broncho- 
pneumonia; but  occasionally  to  erysipelas  of  the  wound  and  diphtheritic  col- 
lapse. On  an  average  the  greatest  danger  to  life  was  from  the  second  to  the 
fourth  day  after  the  operation.  Speaking  of  the  associated  conditions  and  symp- 
toms, Dr.  Henoch  said  that,  scarlatinal  cases  excluded,  cutaneous  eruptions  were 
rare.  In  three  cases  a  diffuse  ulticaria-like  erythema  was  noted  over  the  nates 
and  extensor  surfaces  of  the  extremities.  Swelling  of  the  submaxillary  glands 
was  constantly  observed  ;  but  except  in  highly  malignant  cases  it  did  not  pass  on 
to  suppuration.  In  no  case — except  one  doubtful  scarlatinal  one — was  there 
swelling  of  joints  ;  nor  endocarditis,  which  was  never  found  post-mortem.  Albu- 
minuria was  most  common,  and  if  it  reached  an  amount  of  about  one-third  or 
more  was  regarded  as  of  bad  prognostic  significance  ;  for  in  such  a  case  it  indi- 
cated either  intense  blood-poisoning  or  nephritis,  which  per  se  was  an  element  of 
danger  even  after  the  diphtheria  had  passed  away.  Dropsy,  however,  rarely 
occurred,  and  uraemic  symptoms  were  never  observed.  This  nephritis,  which 
could  hardly  be  considered  a  true  sequel,  was  frequently  associated  with  cardiac 
debility,  the  occurrence  of  inflammations,  and  diphtherial  paralyses.  The  use  of 
corrosive  sublimate  as  a  gargle,  of  arsenic  and  iron,  and  of  papayotin  in  serious 
cases,  was  advocated. — Lancet,  Nov.  29,  1884. 

The  Symptoms  of  Rickets  considered  in  relation  to  their  Anatomical  Origin. 

M.  Kassowitz,  in  an  article  in  the  Jahrbuch  fur  Kinderheilkunde,  Bd.  xxii. 
p.  60,  says  that  the  most  striking  feature  in  the  microscopic  anatomy  of  rickets  is 
the  hyperaemia  and  increased  vascularity  of  all  the  tissues,  and  especially  of  those 
in  which  the  growth  of  the  young  bone  is  going  on.  It  is  to  be  seen  in  marrow, 
cartilage,  and  periosteum,  as  well  as  in  the  bone  itself.  Indeed,  a  new  formation 
of  bloodvessels  takes  place,  and  vessels  are  to  be  found  in  places  where  normally 
there  are  none.  This  increased  vascularity  must  be  considered  the  primary  lesion 
out  of  which  all  the  others  arise.  It  acts  in  two  ways :  firstly,  it  disturbs  the 
course  of  development  of  the  growing  bone  ;  and,  secondly,  it  sets  up  unhealthy 
processes  Avithin  bone  already  formed.  In  the  growing  bone  excess  of  nutritive 
material  causes  excessive  proliferation  of  cartilage  cells,  and  a  consequent  loss  of 
firmness  in  the  cartilaginous  tissue :  the  cells  are  increased  in  size  and  number, 
and  the  matrix  is  also  more  abundant  and  softer  than  usual.  There  is  also  an 
increase,  in  the  earlier  stages  of  rickets,  of  the  area  of  ossification ;  but  the  bone 
thus  formed  does  not  become  thoroughly  firm,  because  the  involution  of  the  ves- 
sels, which  is  a  necessary  process  in  the  formation  of  healthy  bone,  does  not  take 
place.  The  result  is  a  loosely-formed  bony  tissue  wanting  in  compactness  and 
solidity.  In  the  bone  already  formed,  the  hyperaemia  of  the  surrounding  tissues 
has  an  equally  disastrous  action ;  the  normal  processes  of  absorption  and  addition 


1885.] 


Medicine. 


257 


are  disturbed,  absorption  taking  place  more  rapidly,  while  the  newly-added 
material  is  less  rich  in  chalky  salts — the  whole  bone  substance  thus  becoming 
more  yielding  and  wanting  in  strength.  In  this  manner  the  bones  may  become, 
in  severe  cases,  quite  soft  and  elastic.  A  careful  examination  of  the  dissected 
bones  often  shows  minute  fractures  of  the  bony  shell,  these  fractures  occurring 
most  frequently  on  the  convex  side  of  the  bent  parts.  But  it  is  impossible  to 
make  them  out  on  the  living  subject.  Complete  fractures  with  crepitus  and  dis- 
placement are  very  rare.  The  pathology  of  rickets  being  as  above  described,  the 
process  of  cure  consists  in  a  converse  movement ;  the  hyperemia  ceases,  the 
superabundant  bloodvessels  are  gradually  obliterated,  this  involution  being  accom- 
panied, as  is  always  the  case  both  in  normal  and  pathological  growth  of  bone,  by 
a  concentric  deposit  of  new  bony  tissue  in  the  area  of  the  obliterating  vessels, — 
the  new  bone  thus  deposited  becoming  exceptionally  hard  and  dense.  After 
laying  down  these  principles  as  applying  to  rickets  in  every  situation,  the  author 
proceeds  to  consider  at  great  length  the  changes  which  take  place  in  the  indi- 
vidual bones.  The  paper  is  to  be  concluded  in  a  future  number. — Edinb.  Med. 
Journ.,  Dec.  1884. 

Phosphorus  in  the  Treatment  of  Tubercular  Disease. 

Tubercular  meningitis  is  generally  admitted  to  be  one  of  the  most  hopeless  of 
the  diseases  which  a  physician  can  be  called  upon  to  treat.  This,  doubtless,  is 
the  explanation  of  the  fact — which  comes  also  as  a  somewhat  humiliating  com- 
mentary on  the  present  limitation  of  our  knowledge  and  the  instability  of  our 
theories  as  to  the  cause  and  nature  of  the  malady — that  the  recommendation  of  a 
certain  preparation  of  phosphorus,  made  a  short  time  since  by  a  correspondent 
of  one  of  our  contemporaries,  led,  in  the  course  of  two  or  three  days  only,  to  the 
exhaustion  of  the  whole  of  the  stock  then  in  the  hands  of  the  manufacturers  as 
well  as  of  the  retail  dealers.  The  value  of  some  combinations  of  phosphorus,  of 
the  hypophosphites  especially,  has  been  lauded  by  several  competent  observers, 
in  the  treatment  of  pulmonary  and  other  affections  which  were  believed  to  own 
a  tubercular  origin,  although  we  experience  some  difficulty  in  assigning  its  just 
value  to  the  specific  adjective  in  this  connection,  inasmuch  as  one  of  the  advocates 
of  the  hypophosphite  treatment  has  recently  stated  his  belief  that  the  drug  is 
only  of  real  curative  value  in  those  cases  in  which  the  typical  bacilli  are  absent. 
Phosphorus,  pure  and  uncombined,  however,  is  seldom  or  never  administered 
as  a  curative  agent  in  cases  of  tubercular  meningitis.  The  remedies  now  most 
employed  may  be  said  to  be  chosen  mainly  with  the  object  of  avoiding  or  of 
allaying  those  symptoms  of  cerebral  irritation  which  are  usually  the  most  painful, 
as  they  are  apt  to  be  the  most  conspicuous  features  of  the  disease.  This,  of 
course,  is  treatment  only  of  a  palliative  sort ;  it  does  not,  admittedly,  go  down 
so  far  below  the  surface  phenomena  as  to  attempt  to  deal  explicitly  with  the 
formation,  the -growth,  the  very  existence  of  that  tubercular  plasm  whose  pres- 
ence is  the  exciting  cause  of  the  symptoms  by  which  we  have  learned  to  recog- 
nize its  nature.  And  palliative  treatment,  in  cases  such  as  these  almost 
invariably  are — cases  in  which  the  hopelessness  of  recovery  is  so  enormous,  and 
so  generally  admitted,  that  it  effects  and  seems  almost  to  justify  a  therapeutic 
paralysis — really  resolves  itself,  if  we  dare  to  look  the  matter  in  the  face,  into  a 
barely  disguised  ordering  of  euthanasia.  Cases  of  complete  and  permanent 
recovery  from  "tubercular"  affections  of  the  lungs  (whatever  be  the  precise 
nature  of  the  lesions  grouped  under  that  rather  vague  terminology)  occur  much 
less  rarely  than  the  pathologist  of  a  generation  since  would  have  believed 
possible.  Good  observers  hold  that  there  is  evidence  of  similar  favorable  results 
No.  CLXXYII  Jan.  1885.  17 


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[Jan. 


having  been  attained  in  some  cases  of  encephalic  tuberculosis,  despite  the  greater 
delicacy  and  importance  of  the  structures  involved  in  the  cacopraxis,  and  this 
even  in  patients  of  an  age  at  which  the  nervous  centres  are  specially  susceptible, 
and  the  whole  bodily  economy  less  capable  of  resisting  the  depressing  influences 
of  disease.  But  such  observers  are,  as  a  rule,  the  first  to  admit  that  these 
instances  are  among  the  rare  and  happy  surprises — the  fortunate  accidents — and 
by  no  means  the  rule  of  practice.  Their  total  is  so  few,  and  their  occurrences 
are  so  far  between,  as  to  force  us  to  the  conclusion  that  recovery,  when  it  does 
take  place,  is  in  spite  of,  rather  than  because  of,  the  therapeutic  measures  which 
have  been  used  ;  a  conclusion  which  is  only  further  strengthened  if  we  admit,  as 
some  would  have  us  do,  that  many  recoveries  from  tubercular  disease  pass 
unnoticed  simply  because  the  disease  itself  has  not  been  recognized. 

Phosphorus,  given  in  the  uncombined  state,  is  recommended  in  various  con- 
ditions of  ill-health  which  are  supposed  to  be  connected  with  some  form  of 
' '  nervous' '  disorganization .  No  one  doubts  that  the  pure  drug  is  at  least  potent ; 
and  there  is  ample  evidence  that,  in  some  cases  at  all  events,  it  is  valuable. 
Phosphorus  is  generally  regarded  as  a  nervine  stimulant ;  when  given  in  thera- 
peutic doses  it  probably  has  no  claim  to  such  a  qualification.  One  at  least  of  the 
stimulant  properties  with  which  it  is  commonly  credited — an  aphrodisiac  action — 
is,  as  Dr.  Phillips  insists,  simply  non-existent.  It  is  probably  far  less  an 
excitant  than  a  corroborant  or  conservator  of  nervous  energy  ;  and  hence  in 
appropriate  cases,  its  action  is  strengthening  rather  than  exhausting.  There  is  a 
form  of  ' '  nervous' '  headache  in  which  phosphorus  gives  prompt  relief ;  in  that  con- 
dition of  languor  and  undefinable  malaise  from  which  some  young  people  of  a 
tubercular  diathesis  are  apt  to  suffer,  it  often  proves  most  useful ;  and  in  certain 
neuralgias,  and  especially  in  the  neuralgia  of  nursing  women,  to  whom  the  usual 
hsematinies  have  perhaps  been  given  in  vain,  it  commonly  acts  like  a  charm. 
We  are  scarcely  justified  then,  it  seems,  in  regarding  phosphorus  as  a  direct 
stimulant  to  cerebral  activity ;  its  action  is  less  perhaps  on  the  nerve  cell  than  on 
its  surroundings,  and  especially  on  its  blood  supply  ;  and  if  its  therapeutic  effect 
is  displayed  rather  in  the  husbanding  of  static  nervous  energy  than  in  securing 
its  too  ready  dissipation,  we  should  have  less  dread  of  administering  it  in  those 
conditions  of  disease  in  which  the  nervous  centres  are  apt  to  be  simultaneously 
excited  and  exhausted.  The  popular  application  of  the  ohne  Phosphor  keine 
Gedanke  theory  scarcely  accords  with  the  teachings  of  modern  science,  which 
again  attaches  less  importance  than  formerly  to  the  two  per  cent,  with  which 
phosphorus  is  accredited  in  the  composition  of  brain-tissue.  Indeed,  we  might 
say  that  phosphorus  is  more  important  to  the  maintenance  of  nervous  energy 
than  to  the  display  of  nervous  activity ;  that  it  is  less  essential  as  a  nerve  food 
than  as  conditioning  nerve  nutrition ;  that  it  is  more  directly  concerned  with 
nervous  health  than  with  nerve  work. 

In  addition  to  this  view  of  the  value  of  the  drug,  the  possibility  of  its  action 
as  a  directly  curative  agent  in  cases  of  tubercular  disease  is  suggested  by  a  con- 
sideration of  the  results  claimed  for  phosphorus  in  the  treatment  of  rickets.  In 
1872  Wegner  published  the  results  of  experiments  showing  the  effects  of  phos- 
phorus, given  in  oily  solution  or  in  emulsion,  in  solidifying  the  growing  bones 
of  both  animals  and  human  beings.  Kassowitz  [Arch.  f.  Kinderh,,  B.  5,  H.  3 
and  4)  has  repeated  and  extended  these  experiments.  Like  Wegner,  he  found 
that  under  the  influence  of  very  minute  doses  the  compact  was  increased  at  the 
expense  of  the  cancellous  tissue  ;  but  he  proved,  in  addition,  that  this  increase 
was  due  to  a  shrinkage  of  the  medullary  spaces,  and  not  to  any  fresh  disposition 
of  bone.  On  gradually  increasing  the  dose,  however,  a  point  is  reached  at  which 
the  action  of  the  drug  appears  to  be  reversed,  so  that  cancellous  tissue  is  found 


1885.] 


Medicine. 


259 


even  under  the  periosteum,  and  the  medullary  spaces  are  increased  in  size,  with 
the  formation  of  numerous  greatly  diluted  bloodvessels.  The  rachitic  process 
thus  artificially  produced  is  an  inflammatory  one,  and  is  displayed  in  the  ends  of 
the  diaphyses.  In  some  of  the  animals  experimented  upon,  the  sciatic  nerve  of 
one  side  had  been  divided  ;  but  as  this  made  no  difference  in  the  results  as  affect- 
ing the  two  limbs,  it  may  be  concluded  that  the  drug  acts  through  the  blood  and 
not  by  nervous  influence.  Since  1879  Kassowitz  claims  to  have  treated  560 
rachitic  children  by  the  plan. thus  suggested,  giving  T^  to  ^  of  a  grain  a  day, 
with  remarkable  and  uniform  success.  The  value  of  this  treatment  of  rachitis 
is  supported  by  Soltmann,  but  is  opposed  by  Schwechten,  and  by  Weiss  of 
Prague.  The  results  of  the  experiments  on  which  it  is  based,  however,  have  a 
direct  bearing  upon  the  treatment  of  tubercular  disease  by  phosphorus.  If  small 
doses  of  this  remedy  produce  marked  constriction  of  the  bloodvessels,  especially 
in  young  and  rapidly  growing  tissue,  it  does  not  appear  unreasonable  to  suppose 
a  gradual  starvation  of  tubercular  nodules,  with  consequent  shrinkage  and  desic- 
cation. Cases  of  "cured  tubercle"  are  recognized  by  the  discovery  of  encysted 
caseous  or  cretaceous  masses ;  and  it  is  noticeable  that  those  drugs  which  have 
been  found  useful  in  tubercular  meningitis  (although  mostly  given  for  other 
reasons),  such  as  opium  (Bristowe),  codeia,  (Harley),  chloral,  bromide  of  potas- 
sium, etc.,  possess  the  power  of  diminishing  the  calibre  of  the  bloodvessels. 
Practice  is  the  only  bar  at  which  appeals  of  this  kind  can  be  judged  ;  as  yet  we 
are  still  in  the  region  of  theory  and  empiricism  on  this  question.  We  would  raise 
no  hopes,  we  have  no  ambition  to  see  an  addition  to  the  list  of  so-called 
"specific"  remedies  But  tubercular  meningitis  is  a  very  fatal  disease,  for 
which  at  present  we  know  of  no  hopeful  treatment.  If  we  agree  with  Trousseau 
that  "imminent  peril  justifies  the  extremity  of  daring,"  we  may  not  unreason- 
ably receive  without  prejudice  a  plan  of  treatment  which  comes  before  us  with 
at  least  some  theoretical  advantages. — Medical  Times  and  Gazette,  Oct.  4,  1884. 

Bony  Tumor  of  Brain. 
The  formation  of  true  bony  growths  in  the  substance  of  the  brain  is  believed  to 
be  of  rare  occurrence.  It  is  possible  that  the  apparent  rarity  is  due  to  the  infre- 
quency  of  post-mortem  examinations  of  the  cranial  cavities  of  senile  individuals. 
M.  Witkowski  has  placed  on  record  some  of  the  particulars  of  an  example  of 
osseous  tumor  of  the  brain.  The  morbid  growth  was  of  the  size  of  a  walnut, 
and  occurred  in  the  left  hemisphere  at  its  occipital  part ;  it  was  quite  independ- 
ent of  the  pia  mater  or  ependyma,  being  surrounded  on  all  sides  by  brain  matter. 
Its  shape  was  like  that  of  two  pyramids  set  together  at  their  bases ;  its  surface 
was  studded  with  a  number  of  spicules,  points,  and  folds,  the  last  of  which  had  a 
certain  resemblance  to  the  convolutions  of  the  brain.  The  tumor  was  encased  in 
a  fibrous  capsule,  and  presented  many  excavations  filled  with  brownish  or  yellowish 
soft  material,  which  was  discovered  on  microscopical  examination  to  be  of  the 
same  structure  as  the  marrow  of  bone.  The  fibrous  capsule  or  periosteum  of  the 
tumor  was  composed  of  a  dense  connective  tissue,  calcified  in  parts.  After  the 
tumor  had  been  decalcified  by  treatment  with  chromic  and  nitric  acids,  a  hyaline 
ground  substance  was  brought  into  existence,  and  lamellse  with  bone  corpuscles 
and  Haversian  canals  were  to  be  seen.  The  tumor  was  connected  with  the  ner- 
vous substance  by  means  of  a  delicate  connective  tissue  strewed  with  amyloid 
corpuscles.  There  were  no  other  osseous  formations  in  any  part  of  the  central 
nervous  system.  The  brain  on  the  same  side  as  the  tumor  was  certainly  more 
consistent  than  the  right  hemisphere,  and  the  microscope  exhibited  an  increase  in 
the  amount  of  connective  tissue  and  stellate  cells.    The  cerebral  arteries  were 


260 


Progress  of  the  Medical  Sciences. 


[Jan. 


extensively  thickened,  and  many  small  foci  of  the  brain  were  in  a  state  of  soften- 
ing. Some  degree  of  internal  and  external  hydrocephalus  was  found,  and  the 
ependyma  was  thickened.  The  brain  was  that  of  a  man,  aged  seventy-nine 
years,  who  had  never  shown  any  symptoms  of  brain  mischief  during  life.  No 
accident  could  be  assigned  as  the  cause  of  the  formation,  which  does  not  appear 
to  have  been  an  ordinary  psammoma. — Lancet,  Oct.  11,  1884. 

Varices  of  the  Oesophagus. 

M.  Hans  Bendz  has  recently  called  attention  to  varices  of  the  oesophagus 
caused  by  circulatory  troubles  of  the  portal  system,  especially  in  cirrhosis  of  the 
liver.  After  a  rapid  introduction  of  his  subject,  he  gives  a  detailed  history  of  the 
case  which  called  out  his  article. 

The  case  in  question  was  that  of  a  man,  set  55  years,  who,  after  about  a  year, 
showed  evident  symptoms  of  cirrhosis  of  the  liver  with  a  considerable  degree  of 
ascites,  and  died  suddenly  from  profuse  hasmatemesis.  The  stomach  and  small 
intestine  contained  a  considerable  quantity  of  blood  at  the  autopsy  ;  the  mucous 
membrane  was  of  normal  condition,  and  was  diffusely  red,  sometimes  a  clear 
red,  sometimes  deep.  The  liver  was  cirrhotic.  The  oesophagus  showed  in 
its  inferior  portion  tortuous,  dilated,  varicose  submucous  veins.  At  the  summit 
of  a  varix  was  encountered  a  longitudinal  opening  with  thin  and  pale  edges. 
The  author  emphasizes  the  fact  that  the  opening  was  only  discovered  by  the 
swelling  of  one  of  the  trunks.  There  is  no  doubt  but  that  all  the  blood  which 
escaped  from  the  mouth,  and  which  was  found  in  the  intestinal  canal,  escaped 
from  this  opening.  Bendz  mentions  a  case  observed  by  Odenius,  but  not  yet 
published.  In  this  case  also  there  was  cirrhosis  of  the  liver,  with  considerable 
ascites.  On  the  day  on  which  the  patient  died  a  considerable  quantity  of  bloody 
fluid  escaped  from  the  mouth,  and  at  the  autopsy  a  bloody  liquid  was  found  in 
the  stomach  and  small  intestine.  The  mucous  membrane  was  neither  infiltrated 
with  blood  nor  tumefied,  but  was  in  a  normal  state.  The  veins  of  the  lower  por- 
tion of  the  oesophagus  were  distinctly  dilated.  Bendz  shows  that,  as  in  his  case, 
the  hemorrhage  came  from  the  oesophageal  veins,  and  believes  that  such  an  open- 
ing as  he  has  described  may  be  easily  overlooked  at  the  autopsy  unless  great  care 
be  exercised. 

In  the  eighth  case  (nineteen  were  collected)  observed  by  Bendz,  the  varices 
were  similar  to  those  in  the  first  case,  but  there  was  no  hemorrhage  and  the  cir- 
culatory disturbance  was  not  so  marked.  The  author  thinks  that  this  disturb- 
ance was  due  to  the  fact  that  the  patient's  respiration  had  been. of  the  abdominal 
type  for  several  years,  thus  subjecting  the  liver  to  a  pressure  which  interfered 
with  the  free  passage  of  the  blood  through  the  portal  vein.  In  five  of  the  cases 
collected  the  circulatory  disturbances  were  distinct  and  important,  and  the 
hemorrhages  considerable  and  fatal. 

From  a  consideration  of  these  cases  Bendz  passes  to  a  consideration  of  the 
relations  and  importance  of  varices  of  the  oesophagus.  Though  they  were  re- 
cognized many  years  ago,  it  is  only  in  the  last  ten  years  that  any  importance 
has  been  attached  to  them  ;  which  is  explained  by  the  fact  that  it  is  only  within 
that  time  that  the  bearings  of  portal  disturbance  on  the  general  circulation  have 
been  more  fully  recognized.  Bendz  draws  a  marked  distinction  between  true 
varices  of  the  oesophagus,  varices  pertaining  almost  exclusively  to  the  lower  por- 
tion of  the  oesophagus,  and  the  phlebectasias  often  encountered  in  persons  of 
advanced  age,  which  are  found  all  along  the  canal,  though  principally  in  the 
upper  portion.  With  the  latter  he  does  not  concern  himself  in  this  paper. 
The  origin  of  the  first  is  clear ;  they  are  formed  just  as  other  vascular  dilatations 


1885.] 


Medicine. 


261 


in  other  parts  of  the  body.  Bendz  severely  criticizes  the  interpretation  given  by 
Neelsen,  of  the  origin  of  varices  of  the  portal  vein  in  general.  Neelsen  has 
taken  no  account  of  the  fact  that,  in  all  the  cases  cited  by  him,  the  varices  occupy 
the  same  part  of  the  portal  system.  Nor  can  Bendz  indorse  the  theory  of 
Chautemps,  referred  to  by  Dussausay.  From  Zenker's  statistics  it  would  seem 
that  true  varices  of  the  oesophagus,  even  in  cases  of  cirrhosis  of  the  liver,  are  rare. 

As  regards  the  anatomy  of  these  varices,  the  question  arises  :  Does  the  oesopha- 
geal circulation  belong  to  the  portal  system?  Dussauday,  relying  on  the  facts  in 
a  case  examined  by  him,  presumes  that  most  of  the  oesophageal  veins  belong  to 
the  portal  system.  Bendz,  on  the  contrary,  concludes  from  the  fact  that  Fiirst 
has  examined  twelve  cases  without  finding  such  connections,  that  it  is  only  in 
exceptional  cases  that  the  oesophagus  furnishes  a  greater  or  less  amount  of  blood 
to  the  portal  vein.  These  exceptional  cases,  however,  are  of  great  importance 
in  the  formation  of  varices  of  the  oesophagus.  If,  in  a  parallel  case,  a  trouble  of 
the  portal  circulation  is  brought  about,  there  are  more  open  and  spacious  ways 
for  a  supplementary  circulation,  and  varices  may  be  more  easily  formed  than  in 
ordinary  cases,  in  which  the  communication  is  made  by  the  submucous  veins  of 
the  cardia  alone.  From  the  situation  of  the  varices  in  some  of  these  cases, 
Bendz  concludes  that  they  are  due  to  an  abnormal  distribution  of  the  veins. 

The  local  sequelas  of  varices  of  the  oesophagus  are  dilatation  of  the  canal,  caus- 
ing dysphagia,  and  erosions  of  the  mucous  membrane  covering  the  principal 
vessels.  Their  general  importance  is  principally  due  to  the  fact  that  they  may 
cause  hemorrhages  by  rupture  or  by  ulcerations.  On  the  one  hand  they  are  of 
such  a  nature  as  to  render  good  service  by  furnishing  a  supplementary  circula- 
tion, and  thus  preventing  ascites.  On  the  other  hand,  this  may  render  the  diag- 
nosis very  difficult,  especially  if  the  cutaneous  veins  are  not  dilated  at  the  same 
time.  From  what  was  found  in  the  first  two  cases,  Bendz  does  not  agree  with 
Dussausay  in  thinking  that  the  development  of  varices  of  the  oesophagus,  in  cases 
of  cirrhosis  of  the  liver,  will  always  prevent  ascites. — ^Nordiskt  Medicinskt  Arkiv, 
Bd.  xvi.,  lift.  9. 

Infections  and  Parasitic  Pneumonia. 

Prof.  Germain  See  read  a  paper  on  this  subject  before  the  Academie  des 
Sciences,  on  Nov.  24th.  Whilst  of  late  years,  he  said,  pneumonia  has  been  re- 
garded as  the  type  of  simple  inflammation,  the  cause  of  this  inflammation  has 
been  attributed  to  cold.  Struck  by  the  observation  of  a  number  of  cases  in 
which  pneumonia  behaved  as  a  true  infectious  disease,  successively  attacking 
several  members  of  one  family,  he  has,  in  his  clinical  lectures  at  1'  Hotel-Dieu, 
opposed  the  classic  doctrine  since  1882,  and  has  taught  the  infectious  nature  of 
the  disease.  Since  that  time  numerous  cases,  published  in  England,  Germany, 
and  elsewhere,  seem  to  prove  that  pneumonia  may,  under  certain  circumstances, 
be  developed  as  is  typhoid  fever,  breaking  out  in  a  prison,  a  school,  barracks,  or 
a  village,  and  attack  a  large  number  of  people  just  as  one  of  the  more  clearly 
defined  infectious  diseases.  The  question  therefore  arises  :  Are  these  cases  to  be 
considered  as  a  special  variety  of  pneumonia  or  only  ordinary  pneumonia  ?  The 
answer  is  that  the  identity  of  the  two  kinds  of  pulmonary  inflammation  has  been 
demonstrated  ;  there  is  no  pneumonia  originating  from  cold  ;  whether  occurring 
as  a  sporadic  or  epidemic  disease,  pneumonia  is  always  parasitic. 

The  micro-organism  of  pneumonia  was  simultaneously  demonstrated  in  Ger- 
many by  Friedlander,  and  in  France  by  Talamon,  Prof.  See's  Chef  de  Clinique. 
According  to  Talamon,  the  parasite  of  pneumonia  is  an  oval  micrococcus,  from 
1  fjL  to  1.50  [i  long,  and  from  .50  to  1  ft  broad  ;  it  is  constantly  found  in  hepatized 


262 


Progress  of  the  Medical  Sciences. 


[Jan. 


lung  tissue.  As  seen  in  the  fibrinous  exudation,  it  has  the  form  of  a  grain  of 
wheat.  Cultivated  in  a  liquid  medium,  in  alkalinized  solution  of  meat  extract, 
it  is  elongated,  tapering,  and  looks  like  a  grain  of  barley.  It  is  sometimes  single, 
sometimes  coupled  two  together  as  diplococci,  and  sometimes  occurs  in  chains  of 
four.  Friedlander' s  description  is  very  similar  to  that  of  Talamon,  but  he  claims 
to  have  also  found,  besides  the  pneumonic  cocci,  a  capsule  which  he  regards  as 
the  essentially  characteristic  element  of  the  micrococcus.  This  capsule  does  not 
exist,  and  has  nothing  to  do  with  the  micrococcus  :  it  is  a  result  of  his  method  of 
preparing  and  coloring  the  exudation.  Frankel,  at  the  last  Berlin  Congress, 
declared  that  the  capsule  is  not  a  constant  phenomenon ;  that  it  may  be  found 
entirely  irrespective  of  any  micro-organisms,  and  that  the  capsules  cannot  possibly 
be  considered  as  characteristic  of  the  micrococci  of  pneumonia  ;  and  Friedlander 
has  recently  renounced  the  idea  that  it  is  in  any  way  distinctive  of  the  pneumonic 
micro-organism. 

AVhatever  it  may  be,  this  micrococcus  is  not  found  in  the  inflamed  lung  alone  ; 
it  has  been  isolated  and  cultivated  in  a  liquid  and  solid  medium  ;  and,  inoculated 
in  animals,  has  produced  lobar  pneumonia,  such  as  is  seen  in  man.  Thus  far, 
no  irritating  substance  introduced  into  the  respiratory  passages  has  caused  lesions 
characteristic  of  frank  pneumonia ;  a  special  action  of  the  micro-organism  is 
needed  to  cause  it.  Friedlander  and  Talamon,  by  injecting  cultures  of  the 
micrococcus  into  the  lungs  of  mice  and  rabbits,  have  caused  typical  cases  of 
pneumonia,  precisely  similar  to  that  occurring  in  man.  In  a  number  of  cases 
the  microbe,  by  emigrating  from  the  lung  and  invading  neighboring  organs,  has 
caused  at  the  same  time  pleurisy  and  fibrinous  pericarditis  of  the  same  nature  as 
the  pulmonary  inflammation. 

From  these  facts  we  cannot  hesitate  to  regard  pneumonia  as  a  specific  parasitic 
disease ;  it  may  be  reproduced  in  animals,  but  the  reproduction  is  impossible 
with  ordinary  irritants,  physical  or  chemical.  In  order  that  the  characteristic  in- 
flammation be  developed,  it  is  necessary  that  a  special  microphyte  be  brought 
in  contact  with  the  lung  tissue,  and  there  multiply.  The  inflammation  remains 
localized  as  long  as  the  micro-organism  does  not  pass  the  limits  of  the  pulmonary 
tissue  ;  this  is  simple  pneumonia.  It  extends  and  becomes  generalized  when  the 
microbe  invades  the  general  circulation,  either  through  the  lymphatic  or  vascular 
system  ;  when  it  becomes  infectious  pneumonia. 

This  parasitic  pneumonia  may  be  absolutely  distinguished  from  the  other  forms 
of  acute  pulmonary  inflammation,  usually  described  under  the  name  broncho- 
pneumonia. Without  doubt,  microbes  also  play  a  part  in  these  cases  ;  but  that 
part  is  secondary  ;  the  course  of  the  disease,  as  well  as  the  extension  of  the 
lesion,  is  here  dominated  by  the  existence  of  a  previous  bronchitis,  due  to  the 
influence  of  cold,  and  by  the  propagation  of  this  bronchitis  to  the  finer  bronchi 
and  the  alveoli.  Broncho-pneumonia,  developed  from  bronchitis  a  frigore,  has 
nothing  definite  in  its  evolution  ;  it  proceeds  by  successive  and  irregular  stages. 
Like  the  eruptive  fevers,  parasitic  pneumonia  has  a  definite  course.  Its  dura- 
tion is  within  fixed  limits,  and  usually  does  not  last  more  than  six  or  nine  days  ; 
it  is  characterized  by  intense  hyperpyrexia  ;  the  temperature  keeps  at  one  point 
for  about  a  week,  following  an  unvarying  course,  as  in  all  acute  infectious  dis- 
eases, dominating  during  this  period  all  local  manifestations  and  physical  signs, 
and  then  falls  suddenly,  often  ou  the  seventh  day. 

As  regards  treatment,  our  object  should  be  to  tide  the  patient  over  the  seventh 
day,  as  the  disease  usually  declines  at  this  time.  Venesection  and  tartrate  of 
antimony  should  not  be  used.  The  temperature  should  be  kept  down  by  quinine 
and  antipyrine ;  the  patient  kept  up  by  alcohol  and  nourishing  liquid  food. — 
U  Union  Mtdicale,  Nov.  29,  1884. 


1885.] 


Medicine. 


263 


Sclerosis  of  the  Coronary  Arteries  and  the  Affections  depending  upon  it. 

Leyden,  in  an  article  on  this  subject  in  the  Zeitschrift  fur  kiinische  Medi- 
cin,  Bd.  vii.,  says  that  since  a  deeper  insight  has  been  made  into  the  relations  of 
certain  pathological  changes  of  the  heart  with  diseases  of  its  vessels,  the  attention 
of  clinicians  has  been  drawn  to  sclerosis  of  the  coronary  arteries,  and  the  affec- 
tions which  seem  to  depend  upon  it.  Samuelson  found  that  confinement  of  or 
pressure  upon  the  coronary  arteries  caused  a  marked  diminution  of  the  cardiac 
contractions,  with  corresponding  lowering  of  the  blood-pressure ;  whilst  Cohn- 
heim  and  Schulthess-Rechberg  observed  that  after  a  previous  state  of  irregularity 
of  the  pulse,  the  strongly-beating  heart  suddenly  stops. 

Leyden  gives  the  following  as  the  pathological  anatomy  of  the  affection  :  — 

1.  Sclerosis  or  ossification  of  the  coronary  arteries,  without  special  changes  in 
the  heart.  The  heart-muscle  does  not  suffer,  and  the  patient  dies  of  an  inter- 
current disease. 

2.  Acute  thrombotic  softening,  or  formation  of  hemorrhagic  infarctions  in  the 
heart-substance,  consequent  upon  sclerotic  thrombosis  of  the  diseased  arteries — 
myomalacia  cordis  of  Ziegler.  This  leads,  at  a  later  period,  either  to  fatty 
degeneration  in  the  occluded  vascular  districts,  or  to  softening,  the  most  frequent 
cause  of  rupture  of  the  heart. 

3.  The  chronic  form,  fibrous  degeneration  of  the  heart-muscle,  myocarditis 
fibrosa,  arising  from  the  callous-formations  in  the  affected  vascular  districts.  In 
this  manner,  also,  aneurism  of  the  heart  is  frequently  produced  at  the  apex. 

4.  A  combination  of  the  above-mentioned  varieties,  the  most  frequent  of  all. 
Clinically,  these  forms  are  seen  in  a  more  or  less  acute,  or  more  chronic  form, 
and  Leyden  classifies  them  as — 

(1)  Acute  cases,  with  sudden  termination  in  death.  Death  occurs  in  a  faint- 
ing fit,  or  after  an  attack  of  angina  pectoris.  In  some  cases  an  autopsy  shows 
very  marked,  in  others  very  slight,  anatomical  changes  in  the  heart :  rupture  of 
the  heart,  hemorrhagic  infiltration  with  extravasation  of  blood  into  the  pericar- 
dium, softening  or  only  small  foci  of  fatty  degeneration  or  slight  softening  of  the 
heart-muscle.  Whilst  these  cases  are  reported  as  cases  of  embolism  of  the 
coronary  arteries,  we  have  the  symptom  of  slowing  of  the  pulse  (Samuelson)  fre- 
quently very  pronounced,  or  sudden  paralysis  of  the  heart. 

(2)  Cases  of  subacute  course,  showing  that  the  severe  course  of  the  disease 
runs  through  a  number  of  weeks.  There  are  certain  forerunners  of  the  disease — 
as  cough,  dyspncea,  frequent  attacks  of  angina  pectoris,  sometimes  even  dropsy. 
The  patient  may  then  improve  for  a  while,  when  severe  symptoms  will  suddenly 
appear,  and  death  take  place.  An  autopsy  will  show  myomalacia,  hemorrhagic 
infiltration,  fatty  degeneration,  and  signs  of  old  fibrosis. 

(3)  Chronic  cases,  generally  described  as  chronic  myocarditis,  fibrous  myo- 
carditis, dilation  or  aneurism  of  the  heart.  In  persons  of  advanced  age,  heart- 
symptoms  develop  slowly,  and  sometimes  disappear.  There  may  be  attacks  of 
angina  pectoris  or  cardiac  asthma.  The  course  of  the  disease  is  almost  always 
progressive ;  whilst  the  symptoms  increase  the  patient  presents  the  phenomena 
of  severe  disease  of  the  heart,  and  under  the  increase  of  the  asthmatic  attacks, 
and  the  appearance  of  dropsy — and  not  very  seldom  of  delirium,  sometimes,  also, 
in  sudden  attacks — the  disease  terminates  fatally. 

The  symptomatology  of  sclerosis  of  the  coronary  arteries  is  that  of  an  acute  or 
chronic  disease,  with  more  or  less  striking  phenomena,  independent  of  valvular 
affections  of  a  progressive  character,  coming  at  an  advanced  age,  and  leading  to  a 
diminished  functional  activity  of  the  heart.  The  cardiac  symptoms  are  promi- 
nent, the  vital  or  physiological  more  so  than  the  physical ;  and  angina  pectoris, 


264 


Progress  of  the  Medical  Sciences. 


[Jan. 


asthmatic  attacks,  weakness  of  the  heart,  fainting  fits,  changes  in  the  heart's 
activity,  both  in  frequency  and  rhythm,  and  in  some  cases  a  prolongation  of  the 
diastolic  period,  are  seen  in  these  cases.  Physical  examination  shows  dilation  of 
the  left  ventricle,  whilst  the  right  is  usually  hypertrophied.  The  complications 
on  the  part  of  the  respiratory  apparatus  are  cough,  dyspnoea,  catarrhal  affections 
and  attacks  of  pulmonary  oedema.  The  most  frequent  causes  of  arterial  sclerosis 
are  heredity,  the  abuse  of  alcohol,  and  high  living.  Physical  and  mental  strains 
also  play  an  important  part. — Centralbl.  fur  Jclin.  Medicin,  Sept.  20,  1884. 

Acute  Pancreatitis  in  Cliild-bed. 
Dr.  R,.  Haidlen,  of  Stuttgart,  reports  the  following  case  from  Dr.  Fehling's 
private  practice :  — 

A  woman,  set.  33  years,  became  pregnant,  and  during  the  period  of  gestation 
had  considerable  gastric  disturbances  and  headache.  She  was  delivered  with  the 
forceps,  there  was  no  post-partum  hemorrhage,  and  the  after-period  was  normal, 
until  the  third  week  after  delivery,  when  there  was  some  hemorrhage.  A  little 
later  she  had  two  attacks  of  pain  in  the  region  of  the  stomach,  and  five  and  a  half 
weeks  after  delivery  she  had  a  very  severe  attack  of  pain  in  the  pyloric  region,  ac- 
companied by  vomiting.  There  was  no  elevation  of  temperature,  the  pulse  was 
100-104,  and  regular.  The  epigastric  region  was  sensitive  to  pressure,  but  there 
were  no  symptoms  of  peritonitis ;  the  skin  was  pale,  and  not  icteric.  The  patient 
seemed  somewhat  collapsed.  In  the  afternoon  of  that  day  she  seemed  worse,  the 
skin  was  paler,  the  pulse  small  and  more  frequent  (110  to  120),  and  the  vomiting 
had  ceased.    The  sensibilities  were  normal. 

Physical  examination  showed  marked  swelling  of  the  abdomen,  great  sensibility 
of  the  pyloric  region,  the  paranetrium  free,  the  uterus  small,  movable,  not  sensi- 
tive ;  there  was  diarrhoea  ;  the  urine  was  passed  spontaneously  in  considerable 
quantity ;  there  was  a  considerable  amount  of  gas  in  the  intestines.  Warm 
fomentations  were  placed  over  the  painful  regions,  subcutaneous  injections  of 
camphor  were  ordered,  and  champagne  and  fluid  diet.  On  the  following  day  the 
patient  was  better,  but  the  symptoms  returned,  and  she  died  collapsed  in  ninety- 
six  hours. . 

The  autopsy  showed  that  there  was  no  peritonitis,  though  a  small  amount  of  a 
dirty  bloody-looking  fluid  in  the  lower  part  of  the  peritoneal  cavity.  The  organs, 
with  the  exception  of  the  pancreas,  were  normal.  Examination  of  the  pancreas 
showed  that  it  had  undergone  considerable  changes ;  it  was  longer,  thicker,  and 
broader  than  normal,  and  in  only  a  few  places  was  its  normal  color  retained ;  it 
had  changed  almost  entirely  to  a  brownish-red,  blood-suffused  mass,  containing  a 
small  clot  of  blood  on  the  anterior  surface,  in  contact  with  the  mesentery,  but 
there  was  no  perforation  anywhere.  The  adjacent  portion  of  the  mesentery  was 
suffused  with  blood. 

The  microscopic  examination  was  made  by  Prof.  Ziegler.  He  made  the 
diagnosis  as  acute  pancreatitis,  with  hemorrhage  into  the  tissue  of  the  organ  ;  the 
microscope  also  showed  small-celled  infiltration  of  the  pancreatic  tissue.  The 
duct  of  Wirsung  was  somewhat  dilated. 

Dr.  Haidlen,  after  an  extensive  search  for  the  report  of  a  similar  case,  has 
found  an  account  of  the  symptomatology  of  acute  pancreatitis  only  in  Strlimpel's 
Lehrbuch  der  Speciellen  Pathologic  und  Therapie,  Bd.  i.  p.  714.  A  few  cases 
of  inflammation  of  the  pancreas  are  found  in  literature  ;  the  affection  commences 
with  severe  colicky  pain  in  the  epigastrium,  and  vomiting  and  collapse  soon 
follow.  The  pulse  is  small,  the  extremities  cool,  and  death  occurs  in  a  short  time. 
The  pathological  appearances  are  such  as  have  already  been  described.  As  to 
the  etiology,  nothing  is  known. — Centralbl.  fur  Gynakologie,  Sept.  27,  1884. 


1885.] 


Medicine. 


265 


Peptonuria. 

Dr.  Grocco,  of  the  University  of  Pavia,  has  an  article  on  this  subject  in  the 
Annali  Universale  di  Medicina  e  Chirurgia,  August,  1884,  in  which  he  draws 
the  following  conclusions  :  — 

1.  Peptonuria  is  always  a  morbid  symptom,  and  clinically  is  entirely  indepen- 
dent of  albuminuria.  2.  It  is  a  symptom  of  both  local  or  general,  infectious  or 
non-infectious  diseases.  3.  Of  the  general  peptogenic  affections  may  be  men- 
tioned paludium,  typhoid  fever,  scorbutus,  purpura  hemorrhagica,  septicaemia, 
and  acute  phosphorus  poisoning.  4.  The  local  affections  giving  rise  to  pepto- 
nuria are  almost  exclusively  of  an  inflammatory  nature,  with  a  tendency  to  sup- 
puration. Among  these  may  be  mentioned  especially  acute  and  subacute  nephritis. 
5.  Peptonuria  occurs  under  rare  pathological  circumstances ;  as  when  there  is  a 
rapid  development  of  a  malignant  neoplasm.  6.  When  encountered  with  a 
strictly  local  affection  it  is  symptomatic  of  inflammation  tending  to  suppuration. 
— L'  Union  M6d.,  October  12,  1884. 

Large  Enemata  of  Nitrate  of  Silver  in  Chronic  Dysentery. 
Dr.  Stephen  Mackenzie  read  a  paper  on  this  subject  before  the  Clinical 
Society  of  London,  on  November  14th.  He  alluded  to  a  former  series  of  cases 
he  had  brought  before  another  society,  and  stated  that  extended  experience  had 
strengthened  his  belief  in  the  value  of  large  enemata  of  nitrate  of  silver  in  the 
treatment  of  cases  of  chronic  dysentery  or  dysenteric  diarrhoea.  The  mode  of 
procedure  he  adopted  was  as  follows.  The  quantity  of  nitrate  of  silver  to  be 
used  was  dissolved  in  three  pints  of  tepid  water  in  a  Leiter's  irrigating  funnel, 
which  was  connected  by  India-rubber  tubing  with  an  oesophageal  tube  with  lateral 
openings.  The  patient  was  brought  to  the  edge  of  the  bed,  and  made  to  lie  on 
his  left  side,  with  his  hips  well  raised  by  a  hard  pillow.  The  terminal  tube, 
well  oiled,  was  passed  about  eight  or  ten  inches  into  the  rectum,  and  the  fluid 
allowed  to  force  its  way  into  the  bowel  by  gravitation.  The  injection  rarely 
caused  much  pain,  and  often  none.  It  usually  promptly  returned  ;  but,  when 
long  retained,  it  was  advisable  to  inject  chloride  of  sodium,  to  prevent  absorp- 
tion of  the  silver-salt.  Various  strengths  had  been  used,  from  thirty  to  ninety 
grains  to  three  pints  of  water ;  but  usually  one  drachm  of  nitrate  of  silver  was 
employed.  The  treatment  was  based  on  the  view  that,  whatever  the  nature  of 
dysentery,  whether  constitutional  or  local,  in  the  first  instance,  the  latter  effects 
were  due  to  inflammation  or  ulceration  of  the  colon,  which  was  most  effectually 
treated,  as  similar  conditions  elsewhere,  by  topical  measures.  Sometimes  one, 
sometimes  two,  injections  were  required,  and  in  some  cases  numerous  injections 
were  necessary  ;  but  in  all  the  cases  thus  treated,  many  of  which  had  been  unsuc- 
cessfully treated  in  other  ways  previously,  the  disease  had  been  cured.  In  most 
cases  other  treatment  was  suspended,  but  in  some,  Dover's  powder  or  perchloride 
of  iron,  which  had  been  previously  administered,  was  continued  or  subsequently 
prescribed. 

The  cases  narrated  were  these.  1.  One  in  which  the  disease  had  lasted  several 
years  on  and  off ;  two  injections  were  used,  and  the  case  was  cured  in  six  weeks. 

2.  Second  attack,  duration  uncertain  ;  four  injections  used  ;  cured  in  five  weeks. 

3.  Duration  two  months  ;  two  injections  used ;  cured  in  three  weeks  and  a- half. 

4.  Duration  five  years  ;  one  injection  used  ;  cured  in  three  weeks.  5.  Duration 
eighteen  months ;  two  injections  used ;  cured  of  dysenteric  symptoms,  but 
remaining  under  treatment  for  diabetes.  6.  Duration  fourteen  months ;  one 
injection  used ;  cured  in  seven  weeks.    The  treatment,  which  laid  no  claim  to 


266 


Progress  of  the  Medical  Sciences. 


[Jan. 


novelty,  was  brought  forward  to  elicit  the  experience  of  others  who  had  tried  it, 
or  to  induce  others  to  employ  it  in  suitable  cases. 

Dr.  Cullimore  asked  for  information  as  to  the  duration  of  allied  cases  of 
disease  treated  in  the  hospital  by  other  methods  than  that  practised  by  Dr. 
Mackenzie,  and  also  whether  the  author  of  the  paper  was  inclined  to  confine 
such  treatment  to  cases  of  rectal  dysentery,  or  to  apply  it  to  others  as  well.  He 
commented  on  the  fact  that  most  of  the  cases  recorded  were  those  of  sailors,  and 
suggested  that  the  favorable  result  might  be,  in  great  part,  due  to  the  improved 
surroundings  of  the  patients,  the  physiological  rest  and  appropriate  diet,  etc., 
afforded  in  hospital,  as  compared  with  the  depressing  surroundings  of  an  existence 
on  board  ship.  In  his  own  experience  of  the  treatment,  he  found  that  pain  was 
produced,  in  one  case,  on  injection  of  two  pints  of  water,  holding  forty  grains  of 
silver-nitrate  in  solution.  In  another  case  of  dysentery,  due  to  famine,  he 
injected  half  a  pint  of  water  containing  iodoform,  but  without  effecting  any  good 
result.  Opium  and  krameria  were,  in  his  opinion,  the  most  useful  remedies  in 
this  class  of  cases. 

Dr.  S.  Mackenzie  said  he  purposely  used  the  term  chronic  dysentery,  or 
dysenteric  diarrhoea,  in  writing  his  paper,  as  being  most  appropriate  to  the 
kind  of  cases  under  discussion,  these  being  characterized  by  teasing  diarrhoea  and 
considerable  constitutional  disturbance.  In  a  previous  paper,  he  had  explained 
that  the  physicians  at  the  Seamen's  Hospital  had  spoken  hopelessly  of  all  kinds 
of  treatment  ;  but,  at  the  London  Hospital,  greater  opportunities  existed  for 
making  observations  in  this  respect  than  at  any  similar  institution,  with  the  excep- 
tion of  the  one  just  named ;  and  in  all  his  own  cases,  the  effects  of  rest,  opium, 
etc.  had  been  tried  in  vain  before  resort  was  had  to  the  injection-method  of 
treatment.  He  alleged  that  rebellious  cases  were  cured  by  the  enema,  and  that 
it  was,  therefore,  a  resource  to  be  adopted  whenever  the  ordinary  remedies  failed. 
He  himself  would  adopt  it  in  ordinarily  severe  cases  at  the  outset  of  treatment. 
He  had  no  definite  statement  to  make  as  to  the  permanence  of  the  cure,  the  class 
of  patients  concerned  being  the  most  difficult  of  any  to  keep  under  observation ; 
but,  in  this  connection,  it  might  be  interesting  to  the  Society  to  know  that  one 
patient  cured  by  him  had  returned  twelve  months  after  being  discharged,  not  on 
his  own  account,  he  being  still  well,  but  to  solicit  Dr.  Mackenzie's  good  offices  in 
behalf  of  a  friend  who  was  suffering,  as  he  had  been,  from  chronic  dysentery. — 
Brit.  Med.  Journ.,  Nov.  22,  1884. 


SURGERY. 

Extirpation  of  the  Larynx. 
Mr.  Timothy  Holmes  reports  the  case  of  a  man,  set.  63  years,  who  was 
admitted  to  St.  George's  Hospital  on  May  16,  1884.  He  had  been  in  perfect 
health  up  to  Christmas.  Then  he  began  to  complain  a  little  of  sore  throat,  and 
deafness  in  the  left  ear.  Soon  afterwards,  the  neck  became  stiff,  and  he  was 
conscious  of  a  swelling  on  the  left  side.  For  the  past  six  weeks,  he  had  had  dif- 
ficulty in  swallowing  and  breathing.  Solids  seemed  to  stick  about  the  level  of 
the  cricoid  cartilage,  and  sometimes  to  come  up  into  his  mouth  again.  Latterly,  he 
had  had  a  very  troublesome  choking  cough,  with  frothy  blood-stained  expectoration. 
He  had  no  fits  of  dyspnoea,  but  his  breathing  was  becoming  more  difficult.  For 
the  last  month  his  voice  had  been  very  hoarse  ;  he  had  found  it  very  difficult  to 


1885.] 


Surgery. 


267 


talk  long,  and  had  been  forced  to  live  on  fluids.  He  had  been  getting  weak  and 
losing  flesh.  On  admission,  he  seemed  tolerably  well  nourished.  His  complexion 
was  dusky,  and  his  voice  hoarse  and  indistinct ;  respiration  was  noisy  and  labored, 
and  cough  was  frequent.  The  thyroid  cartilage  was  expanded  and  bulged,  espe- 
cially on  the  left  side.  Above  the  larynx,  there  was  considerable  fulness  on  this 
side,  reaching  up  to  the  jaw,  and  extending  in  an  irregular  manner  up  the  neck. 
The  new  growth  here  seemed  firmly  attached  to  the  structm*es  around,  but  the 
trachea  was  quite  free.  The  larynx  was  examined  by  Dr.  Whipham,  who 
reported  that  the  growth  involved  the  epiglottis  chiefly,  but  also,  probably,  the 
arytenoids.  A  portion  of  the  epiglottis  had  been  destroyed  by  the  ulceration  of 
the  growth.    No  view  at  the  larynx  could  be  obtained. 

If  the  case  were  to  be  treated  at  all,  two  courses  presented  themselves  :  to  wait 
until  the  obstruction  to  breathing  or  swallowing  became  formidable,  and  then  either 
perform  tracheotomy  simply,  or  attempt  the  entire  extirpation  of  the  growth  ;  or 
to  make  that  attempt  at  once.  The  fact  that  the  man  was  suffering  more  from 
pain  in  deglutition  than  from  dyspnoea  rendered  it  very  important  to  remove  the 
ulcerated  epiglottis  ;  while  the  extent  to  which  the  disease  already  extended  out- 
side the  larynx  rendered  it  doubtful  whether  it  could  be  removed  even  at  present, 
and  nearly  certain  that,  in  a  little  while,  it  would  be  beyond  the  reach  of  opera- 
tion. Under  ether,  a  vertical  incision  was  made  from  the  hyoid  bone  to  about 
the  fifth  ring  of  the  trachea,  and  was  crossed  by  a  horizontal  incision  ;  and  after 
the  surface  of  the  windpipe  had  been  carefully  exposed  by  dissection,  about  three 
rings  of  the  trachea  were  divided,  and  the  trachea  plugged  with  Semon's  modifi- 
cation of  Trendelenburg's  tampon.  Then  an  incision  was  made  in  the  middle 
line  of  the  cricoid  and  thyroid  cartilages,  with  much  difficulty,  owing  to  their 
extensive  ossification.  The  thyro-hyoid  membrane  was  exposed  and  divided,  the 
upper  corner  of  the  thyroid  separated  from  the  hyoid  bone,  and  the  right  half  of 
the  larynx  removed  ;  on  the  left  side,  the  left  half  of  the  cricoid  cartilage  was  left, 
as  that  cartilage  was  quite  unaffected.  On  that  side,  much  difficulty  was  experienced 
in  defining  the  morbid  mass,  which  lay  external  to  the  larynx,  extending  up  towards 
the  tonsil ;  ultimately,  after  conducting  the  dissection  as  high  as  possible,  it  was  felt 
that  something  had  been  left  behind.  The  pharyngeal  wall  had  been  very  freely 
removed.  Not  much  blood  was  lost,  as  the  vessels  were  easily  secured  as  they 
were  divided.  On  the  termination  of  the  operation,  a  tube  was  passed  down  the 
oesophagus,  and  the  greater  portion  of  the  large  incision  was  united.  He  was  fed, 
partly  through  the  oesophageal  tube,  partly  by  nutrient  enemata,  but  never  ral- 
lied satisfactorily,  and  died  about  forty  hours  after  the  operation.  The  disease 
was  epithelioma,  and  affected  almost  the  entire  epiglottis,  and  the  portions  of  the 
larynx  immediately  adjacent.  The  mass  outside  the  larynx  was  continuous  with 
that  inside,  and  a  portion  of  the  mass  outside  the  windpipe,  on  the  left  side,  had 
been  left  behind,  and  lay  in  contact  with  the  pharynx,  extending  as  high  as  the 
tonsil. 

The  case  seemed  to  be  a  fairly  appropriate  one  for  the  operation,  allowing  the 
operation  to  be  in  itself  justifiable.  It  is  true  that  the  disease  had  spread  external 
to  the  larynx,  and  that  it  might  prove  (as  it  did  prove)  impossible  to  completely 
extirpate  the  disease.  But  this  could  not  be  determined  before  operation.  Ex- 
pectant treatment  held  out  no  better  prospect,  and,  as  there  was  no  serious  dys- 
pnoea, tracheotomy  could  do  no  good.  On  the  other  hand,  the  man  was  rapidly 
wasting  from  the  difficulty  of  swallowing  occasioned  by  the  condition  of  the  epi- 
glottis and  parts  around  it,  and  the  only  chance  of  relieving  this  appeared  to  be 
removal  of  the  affected  parts. 

But  the  history  clearly  shows  how  formidable  the  operation  is,  and  how  uncer- 
tain is  the  prospect  of  even  succeeding  in  removing  the  whole  disease,  when  the 


268 


Progress  of  the  Medical  Sciences. 


[Jan. 


latter  is  of  a  cancerous  nature.  "Readers  of  Mr.  Butlin's  work  on  Malignant  Dis- 
ease of  the  Larynx  will  recollect  that  belays  down  (on  page  63)  the  doctrine  that 
extrinsic  carcinoma  is  an  incurable  disease,  in  which  extirpation  affords  no  pros- 
pect of  benefit ;  and  that,  in  intrinsic  carcinoma,  though  extirpation  may  be  prac- 
tised with  fair  prospect  of  benefit  when  the  disease  is  limited  to  the  laryngeal 
cavity,  yet,  when  it  has  spread  beyond  the  larynx,  or  has  affected  the  glands,  the 
prospect  is  almost  as  hopeless  as  in  extrinsic  carcinoma.  The  above  case  cer- 
tainly supports  this  doctrine. 

I  may  add  that,  if  I  should  ever  be  called  upon  to  repeat  this  operation,  I  think 
I  would  perform  the  preliminary  tracheotomy  a  few  days  previously  to  the  extir- 
pation. The  operation  is  one  attended  with  profound  shock,  as  this  case  testifies, 
even  when  there  is  no  excessive  hemorrhage,  and  no  operative  accident ;  and  this 
might  be  lessened  by  dividing  it  into  two  parts. — British  Medical  Journal,  Oc- 
tober 25,  1884. 

Wounds  of  the  Heart. 

E.  Rose,  in  an  article  on  heart-tamponade  [Deutsche  Zeitschrift  fur  Chirurgie, 
Bd.  xx.  Hft.  5),  contributes  twenty  new  cases  of  wound  of  the  heart,  four  of 
which  he  saw  after  death,  the  other  sixteen  being  treated  by  him.  Wounds  of 
the  heart  are  by  no  means  so  immediately  dangerous  as  is  generally  supposed. 
Of  Rose's  cases  only  one  was  really  killed  by  the  wound,  three  others  died  of 
other  severe  injuries,  and  independently  of  the  heart-wound,  one  fourteen  days 
after  gunshot  wound  of  both  lungs.  In  three  of  these  four  cases  the  wound  of 
the  heart  was  as  good  as  healed  at  the  time  of  death. 

Heart-wounds  are  easily  diagnosticated  from  those  of  the  left  lung,  as  the 
symptoms  of  pneumopericardium  are  very  characteristic.  A  second  class  may  be 
made  of  heart-wounds  without  injury  of  the  lung,  but  with  profuse  external 
hemorrhage.  There  is  a  third  class,  easily  overlooked  or  undervalued,  of  heart- 
wounds  with  or  without  quick  closure  of  the  wound,  as  in  rupture  of  the  heart  by 
fracture  of  the  inbs,  stab-wounds,  etc.  These  cases  are  not  infrequent,  and  the 
heart  should  be  examined  daily.  The  chief  danger  for  the  patients  in  whom,  on 
account  of  the  absence  of  a  wound  or  its  small  size,  there  is  no  immediate  external 
hemorrhage,  is  the  sudden  distension  of  the  pericardium  with  blood — heart-tam- 
ponade. In  this  case  the  action  of  the  heart  is  mechanically  hindered,  so  that  the 
wounded  person  often  dies  very  quickly  of  suffocation,  apparently  of  most  extreme 
cyanosis  and  heart-failure.  This  should  be  prevented  by  absolute  rest  on  the 
back,  ice-bags  to  the  heart,  strict  diet,  etc.  If  it  occurs  in  spite  of  this,  vene- 
section and  removal  of  the  effused  blood  by  opening  the  pericardium  are  recom- 
mended. 

Hegar,  of  Hamburg,  in  commenting  on  this  paper,  says  that  Rose  has  not 
performed  this  operation  which  he  recommends.  He  compares  the  operation 
to  tracheotomy  (for  impending  suffocation),  but  does  not  mention  the  great  dan- 
ger of  a  second  filling  up  of  the  pericardium,  and  a  condition  as  bad  as  at  first. 
The  effect  of  venesection  is  well  seen  by  the  following  case.  A  young  physician 
was  stabbed  in  the  cardiac  region.  Rose  found  him  struggling  for  air,  speechless 
from  dyspnoea,  blue  in  the  face,  and  lying  on  the  bed.  The  pulse  could  not  be 
felt.  In  the  upper  cardiac  region  was  a  knife- wound,  a  finger's  breadth  wide, 
which  did  not  bleed,  and  was  not  gaping.  The  cardiac  dulness  was  enormously 
increased.  Rose  bled  him  profusely ;  the  pulse  became  markedly  better,  and 
the  suffocation  abated.  The  more  the  blood  flowed  the  better  the  pulse  became. 
Rose  thinks  that  he  took  over  two  pounds  of  blood.  The  liEemopericardium  was 
rapidly  absorbed,  and  the  patient  was  healed  in  five  weeks. — Centralbl.  fur 
Chirurgie,  Sept.  20,  1884. 


1885.] 


Surgery. 


269 


Lumbar  Nephrectomy  for  Renal  Calculus. 

At  the  meeting  of  the  Koyal  Medical  and  Chirurgical  Society,  on  Nov.  25, 
Mr.  Henry  Morris  reported  the  case  of  a  laborer,  set.  35  years,  who  had  suf- 
fered from  well-marked  symptoms  of  renal  calculus  of  the  right  side  since  the 
end  of  1881,  and  had  been  under  the  care  of  Dr.  Douglas  Powell  at  the  Middle- 
sex Hospital,  came  again  under  treatment  in  October,  1883.  In  November, 
1882,  Mr.  Morris  had  explored  his  kidney  digitally,  and  with  the  probing  needle, 
but  did  not  detect  the  stone.  On  October  24th,  1883,  the  exploration  was  re- 
peated, but,  again  failing,  the  kidney  was  removed  through  the  lumbar  incision. 
The  patient  made  an  uninterrupted  recovery,  and  at  the  present  time  was  hard 
at  work  as  a  charcoal-burner — "is  as  well,"  his  medical  adviser  reported,  "as 
ever  he  was  in  his  life,  and  able  to  work  without  the  slightest  inconvenience." 
The  kidney  excised  was  of  normal  size  and  appearance,  and  its  secreting  struc- 
ture was  found  by  Dr.  Coupland  on  microscopical  examination  to  be  quite 
healthy.  The  organ,  however,  was  harder  and  tougher  than  usual,  and  con- 
tained a  rounded  rough  calculus,  about  the  size  of  a  marble.  Careful  daily  ex- 
amination was  made  of  the  urine  by  Mr.  Paul  both  before  the  nephrectomy  and 
for  more  than  six  weeks  after  the  operation,  so  that  the  rapidity  and  power  with 
which  one  kidney  could  take  on  the  whole  of  the  excretory  function  were  shown 
in  a  table  which  formed  part  of  the  paper.  The  results  were  equivalent  to  those 
of  a  simple  physiological  experiment,  because  a  healthy  kidney  (as  far  as  its  ex- 
creting substance  went)  was  removed,  and  a  healthy  one  was  left  behind.  A 
comparison  was  made  between  the  lumbar  and  the  peritoneal  methods  of  nephrec- 
tomy. It  was  shown  that  the  arguments  which  had  been  used  in  favor  of  the 
peritoneal  operation  were  more  theoretical  than  practical ;  and  that,  if  followed 
out,  they  were  likely  to  lead  to  pernicious  results.  The  conclusion  arrived  at 
was,  that  lumbar  nephrectomy  was,  as  a  rule,  the  better  operation,  though  there 
were  exceptional  circumstances  and  certain  diseased  conditions  in  which  the  ab- 
dominal method  was  preferable.  In  nephrolithotomy,  the  lumbar  incision,  and 
that  only,  ought  to  be  employed.  In  judging  of  the  condition  of  the  kidney 
opposite  to  the  one  to  be  removed,  we  had  to  depend  upon  the  general  symptoms 
of  the  case,  and  upon  the  amount  of  urea  daily  excreted.  But  it  was  not  correct 
to  infer  that  the  kidneys  were  diseased  because  they  excreted  a  daily  average 
quantity  of  urea  even  less  than  half  the  standard  quantity.  Persons  who  had 
long  been  living  an  invalid  life,  and  who  had  lost  much  flesh,  might,  with  per- 
fectly sound  kidneys,  eliminate  not  more  than  from  .8  to  1.8  per  cent,  of  urea  in 
the  thirty  to  thirty-five  ounces  of  urine  that  they  passed  in  a  day. 

Mr.  Bryant  congratulated  Mr.  Morris  on  his  success,  and  proceeded  to  touch 
on  the  many  interesting  points  in  his  case.  In  the  first  place,  as  a  physiological 
experiment,  it  was  important,  as  showing  that  a  patient  might  do  nearly  as  well 
with  one  kidney  as  with  two.  Again,  the  difficulty  of  diagnosis  of  the  calculus, 
even  after  handling  and  probing  of  the  kidney,  showed  that  nephrolithotomy 
must,  in  all  cases,  be  at  first  an  exploratory  operation.  It  would  certainly  have 
been  better  to  have  taken  away  the  stone,  and  left  the  kidney ;  hence  he  felt  the 
importance  of  Mr.  Morris's  suggestion  to  incise  the  pelvis  of  the  kidney  in  future 
cases,  in  order  to  make  the  search  for  the  stone  more  complete.  In  excision  of 
renal  calculus,  he  thought  the  lumbar  operation  preferable  to  the  peritoneal,  as 
giving  a  better  access  to  the  pelvis  of  the  kidney,  which  lay  behind  the  vessels, 
and  was,  in  many  cases,  the  most  important  point  for  incision.  A  more  general 
and  more  important  point  was  what  was  sufficient  to  justify  the  removal  of  the 
kidney.  In  pyonephrosis  and  hydronephrosis,  he  was  inclined  to  think  it  was 
hardly  ever  necessary ;  by  washing  out  and  draining  the  tumor  through  the  loin, 


270 


Progress  of  the  Medical  Sciences. 


[Jan. 


the  cyst  withered,  and  generally  a  small  discharging  sinus  was  left,  which  was 
not  enough  to  have  justified  a  larger  operation.  He  had  himself  never  removed 
a  kidney,  but  he  had  drained  three  fluid  tumors  of  the  kidney,  with  results  which 
showed  that  more  would  not  have  been  justifiable.  In  one  case,  there  was  still 
a  sinus  discharging  about  four  ounces  daily,  but  that  was  comfortable,  and  no 
further  operation  was  thought  of.  In  some  cases  of  very  slow  improvement,  he 
had  at  first  regretted  that  he  had  not  removed  the  whole  kidney,  but  afterwards 
had  lost  his  regret  on  seeing  them  slowly  recover. 

Mr.  Hulke  had,  like  Mr.  Bryant,  never  removed  a  kidney,  but  had  frequently 
cut  down  upon  one  for  stone,  and  preferred  the  lumbar  incision.  Very  large 
tumors,  he  admitted,  could  only  be  removed  through  an  abdominal  incision,  but 
for  any  but  the  largest  he  should  advise  removal  by  an  extension  of  the  ordinary 
lumbar  incision.  If  an  abdominal  incision  had  been  made  for  the  removal  of  a 
large  pyonephrotic  kidney,  and  then  an  abscess  were  found,  as  would  not  be  im- 
probable, just  behind  the  kidney,  the  danger  of  peritonitis  would  be  much  more 
serious  than  if  the  incision  had  been  lumbar.  Any  operation,  however,  for 
nephrolithotomy  must  be  tentative,  for  the  diagnosis  could  never  be  quite  certain. 
Some  years  ago  a  colleague  of  his  had  thought  he  had  a  renal  calculus,  and  his 
opinion  was  shared,  after  examination,  by  most  skilful  surgeons,  so  that  an  opera- 
tion had  been  determined  upon.  At  the  last  moment,  however,  he  shrank  from 
the  operation,  and  lived  some  time  longer,  and  after  his  death  it  was  conclusively 
shown  that  he  had  had  no  calculus  at  all.  A  boy  under  his  care  had  had  marked 
clinical  symptoms  of  calculus,  and  he  had  examined  the  kidney  through  a  lumbar 
incision,  handled  it  carefully,  and  passed  a  needle  through  it  without  meeting 
with  any  stone,  and  at  the  time  declined  to  go  any  further.  He  felt  now,  after 
hearing  Mr.  Morris's  paper,  that  he  ought  to  have  made  an  opening  in  the  pelvis 
of  the  kidney,  and  to  have  introduced  a  sound. 

Mr.  Knowsley  Thornton  said  he  felt  that  Mr.  Morris  was  to  be  congratu- 
lated on  his  success,  but  at  the  same  time  it  must  be  remembered  that  he  had  had 
an  escape  from  the  calamities  of  surgery.  He  had  himself  twice  made  the  same 
mistake  of  missing  the  calculus,  and  so  could  speak  with  sympathy.  Freer 
incisions  of  the  kidney  might  have  settled  the  point,  and  in  not  undertaking  these 
Mr.  Morris  had  missed  one  of  the  advantages  of  his  lumbar  operation.  The 
symptoms  of  his  case  had  begun,  as  Mr.  Morris  had  told  them,  after  lying  in  a 
damp  barn ;  he  thought  it  not  unlikely  that  such  chills  were  really  one  of  the 
causes  of  the  formation  of  calculi,  and  asked  further  information  from  the  phy- 
sicians. Mr.  Morris  objected  to  his  plan  of  bringing  the  ureter  out  of  the  wound 
in  abdominal  incisions,  as  leading  to  intestinal  obstruction.  But  that  had  not 
been  shown  to  be  the  case,  and  it  had  not  happened  in  former  times  when  the 
much  stouter  ovarian  pedicle  had  been  similarly  dealt  with.  That,  in  fact,  had 
been  proved  to  wither  quickly ;  and  he  could  not  give  up  the  teaching  of  his  ex- 
perience, which  was  that  it  was  better  to  bring  the  ureter  out  of  the  wound.  He 
might  be  in  a  minority,  possibly  of  one,  in  saying  that  he  preferred  operation  on 
the  kidney  through  the  peritoneum  ;  but  he  had  done  it  often  with  success,  and 
he  did  not  think  that  our  present  knowledge  of  renal  surgery  was  sufficiently  ad- 
vanced for  any  very  hard  and  fast  rules.  The  abdominal  operation  certainly 
afforded  the  advantage  of  more  complete  inspection ;  and,  in  a  recent  case,  he 
had  found  great  benefit  result  from  being  able  to  see  exactly  where  the  stone  was 
in  the  kidney,  and  to  make  his  incision  accurately  to  meet  the  circumstances  of 
the  case.  The  objection  to  the  method  hinged  almost  entirely  on  the  fear  most 
surgeons  felt  of  wounding  the  peritoneum,  and  that  he  did  not  himself  at  all 
share ;  he  had  as  soon  wound  the  peritoneum  as  any  other  tissue  in  the  body, 
and  sooner  than  most  others.    He  was  more  inclined  to  remove  the  whole  kidney 


1885.] 


Surgery. 


271 


than  Mr.  Bryant,  for  he  had  done  so,  in  some  bad  cases  more  than  three  years 
ago,  who  were  now  comfortable  ;  and  he  could  not  consider  the  constant  incon- 
venience of  a  renal  sinus  as  anything  less  than  serious.  The  case  which  Mr. 
Hulke  had  suggested,  of  an  abscess  behind  a  pyonephrotic  kidney,  would  be 
certainly  serious,  however  the  operation  had  been  begun ;  but  he  should  have 
been  inclined,  after  opening  the  peritoneum,  to  have  drained  the  abscess  in  the 
loin,  which,  he  thought,  could  certainly  have  been  effected  without  fouling  the 
peritoneum.  In  fact,  he  had  performed  such  an  operation  in  a  case  which  he  had 
shown  recently  at  the  Pathological  Society.  After  lumbar  incisions,  could  it  be 
asserted  that  there  had  been  no  wounding  of  the  peritoneum  ?  He  thought  the 
post-mortem  records  would  show  that  it  could  not.  The  lumbar  operation,  at 
present,  had  statistics  in  its  favor,  but  he  expected  the  results  of  the  peritoneal 
operation  to  prove  themselves  better.  There  was  decided  advantage  in  being 
able  to  see  the  condition  of  the  other  kidney,  and  whether,  indeed,  there  was 
another  kidney.  When  a  kidney  was  in  the  living  body,  and  had  the  blood 
circulating  in  it,  palpation  could  diagnose  much  more  than  when  it  was  dead ; 
and  he  was  almost  inclined  to  think  that,  in  Mr.  Morris's  case,  a  stone  might 
have  been  felt  in  life. 

Mr.  Morrant  Baker  remarked  that  deep  rectal  examination  (as  had  been 
mentioned  by  some)  was  sometimes  dangerous,  and  leads  to  rupture  of  the  bowel, 
and  that  he  could  hardly  think  that  much  additional  information,  in  difficult 
cases,  could  be  gained  in  that  way.  In  his  own  cases  of  nephrectomy  (which 
happened  to  have  been  performed  through  the  loin,  because  there  had  been 
previous  lumbar  incision  for  nephrotomy),  he  had  introduced  his  hand  between 
the  kidney  and  its  capsule,  and  removed  the  kidney  whilst  leaving  the  capsule, 
which  constituted  a  defence  against  wounding  the  peritoneum.  The  cases  were 
getting  worse  after  nephrotomy,  and  it  would  have  been  impossible  to  keep  them 
alive  without  hazarding  the  larger  operation.  One  kidney,  it  had  been  said  that 
evening,  had  been  proved  as  good  as  two,  but  that,  he  thought,  must  be  received 
with  great  caution  when  they  remembered  how  slight  a  strain  was  sufficient  to 
overtax  a  single  kidney.  That  had  been  shown  in  one  of  his  own  cases  after 
nephrectomy. 

Mr.  Henry  Morris  said  that  his  operation  had  certainly  not  proved  a  mis- 
fortune to  the  patient,  for  now  he  was  capable  of  earning  his  own  living.  Mr. 
Thornton  had  suggested  that  he  ought  to  have  made  more  incisions  in  the  kidney 
before  giving  up  the  search  for  a  stone  in  it,  and  he  fully  realized  that  point  now, 
but  before  the  operation  he  had  not  his  present  experience  to  guide  him.  The 
ureter  he  was  still  inclined  to  leave  in  the  wound,  and  not  invite  its  sloughing  by 
dragging  it  to  the  front  of  the  abdomen.  Its  blood-supply  was  so  different  from 
that  of  the  ovarian  pedicle,  that  no  just  comparison  could  be  made  as  to  their 
likelihood  of  sloughing.  He  had  no  fear  of  the  peritoneum,  but  great  respect 
for  it ;  and  he  avoided  trespassing  on  it  as  he  should  avoid  trespassing  on  the 
interior  of  a  joint.  In  cases  of  nephrolithotomy,  he  still  considered  the  argu- 
ments in  favor  of  a  lumbar,  as  opposed  to  a  peritoneal,  incision  to  be  very  strong. 
As  to  the  supposed  advantage  of  a  view  of  the  kidney  not  operated  upon  which 
was  gained  by  an  abdominal  incision,  he  quoted  a. letter  from  Mr.  Bennet  May, 
'  of  Birmingham,  who  had  excised  a  scrofulous  kidney  through  the  loin.  The 
patient  died  in  five  days  ;  and,  when  a  post-mortem  examination  was  made,  and 
the  abdomen  laid  open  more  freely  than  in  any  abdominal  operation,  he  was 
quite  unable  to  detect  the  condition  of  the  other  kidney,  which  was  really  in  a 
state  of  advanced  caseous  degeneration.  He  inferred  that,  in  many  cases,  little 
help  would  be  given  by  inspection,  whereas  in  many  others  it  was  not  wanted. 
Out  of  4632  bodies  examined  at  Guy's  Hospital,  there  had  only  one  case  been 


272 


Progress  of  the  Medical  Sciences. 


[Jan. 


found  in  which  one  kidney  was  absent ;  and  none,  out  of  1200  cases,  at  Middle- 
sex Hospital ;  so  that  that  was  a  chance  that  might  fairly  be  disregarded.  There 
was  a  case,  it  was  true,  in  which  a  woman  with  only  a  single  kidney  had  had  that 
kidney  excised,  but  she  was  a  case  of  great  deformity,  having  no  vagina  and  no 
uterus,  and  the  abnormalities  of  the  genital  organs  were  just  those  which  expe- 
rience has  shown  were  associated  with  renal  malformations.  The  loin  formed  a 
very  convenient  region  for  a  drain,  and  he  was  strongly  in  favor  of  draining  fluid 
tumors  there;  regarding  a  man  from  whom  10  ounces  of  urine  were  drained  in 
the  loin  as  in  a  better  position  than  a  man  with  only  one  kidney. — British  Medical 
Journ.,  Nov.  29,  1884. 

Nephrectomy  for  Calculous  Pyelitis. 
Dr.  E.  Sonnenburg  reports  (Berlin.  Klin.  Wochensch.,  Nov.  24)  the  case 
of  a  woman,  set.  52  years,  who  had  suffered  from  pain  in  the  right  loin  since  last 
Easter,  accompanied  by  fever,  wasting,  and  polyuria.  She  came  under  Dr. 
Sonnenburg's  care  in  August,  when  the  presence  of  a  large  fluctuating  tumor  in 
the  right  half  of  the  abdomen  was  ascertained,  and  on  aspiration  pus  was  drawn 
off  from  it.  Nephrectomy  by  the  abdominal  incision  was  performed  on  August 
25th.  The  operation  was  difficult  and  tedious,  the  thin  wall  of  the  cyst  ruptur- 
ing in  the  removal.  The  whole  pedicle  was  secured  to  the  wound,  but  it  was 
found  impossible  to  suture  the  peritoneum.  The  organ  was  converted  into  a 
chambered,  pus-containing  sac,  with  numerous  thin- walled  outlying  cysts,  and  a 
large  branching  calculus  was  lodged  in  the  dilated  pelvis.  Hardly  any  renal 
tissue  remained.  Great  collapse  followed,  terminating  in  death  on  the  second 
day,  and  during  the  whole  interval  no  urine  at  all  was  secreted.  There  was  no 
peritonitis;  the  left  kidney  weighed  190  grammes,  and  was  anaemic,  but  histo- 
logically almost  normal,  except  for  some  localized  fatty  degeneration  of  the  renal 
cells  and  slight  increase  in  places  of  the  interstitial  tissue.  The  fatal  issue  of  the 
case  could  not,  Dr.  Sonnenburg  thinks,  be  attributed  to  the  shock  of  the  opera- 
tion and  the  collapse  alone  ;  but  that  the  condition  of  anuria,  the  cause  of  which 
remains  unexplained,  was  in  the  main  answerable  for  this  result. — Lancet,  Nov. 
29,  1884. 

Contusions  and  Ruptures  of  the  Intestine  without  Lesion  of  the  Abdominal  Wall. 

M.  Chavasse,  of  the  French  Army,  reports  two  cases  of  injury  of  this  nature, 
and  has  found  149  cases  in  literature. 

The  first  case  which  he  reports  was  that  of  a  man  who  was  kicked  on  the  abdo- 
men by  a  horse.  The  autopsy  showed  multiple  intestinal  lesions,  and  complete 
rupture  of  a  loop  of  the  small  intestine.  The  second  case  was  due  to  the  same 
cause ;  but  the  patient  recovered,  as  the  injuries  were  mild.  In  the  army,  in 
times  of  peace,  contusions  and  ruptures  of  the  intestines  are  almost  always  caused 
by  kicks  from  horses.  In  the  report  of  the  Surgeon-General  of  the  Prussian 
Army  for  1879-81,  Beck  reports  17  cases  due  to  this  cause.  Of  the  149  cases 
collected  by  Chavasse,  this  cause  was  present  in  36  cases,  exclusive  of  those  re- 
ported by  Beck ;  23  cases  were  caused  by  the  passing  of  a  carriage  or  wagon 
wheel  over  the  abdomen  ;  13  were  caused  by  kicks  from  men. 

The  anatomical  lesions  found  at  the  autopsy,  in  the  case  first  reported,  are  of 
considerable  interest.  Three  different  sections  of  the  intestines,  superimposed 
from  before  backwards,  were  injured ;  the  transverse  colon  and  the  duodenum 
were  contused ;  and  a  loop  of  the  small  intestine,  situated  between  them  at  the 
ileo-jejunal  junction,  was  completely  cut  in  two.  The  prevertebral  tissues  were 
infiltrated  with  blood,  and  showed  traces  of  contusion.    It  was  the  least  resistant 


1885.] 


Surgery. 


273 


loop  of  intestine  which,  in  spite  of  its  position  between  the  others,  was  most 
severely  injured.  These  multiple  lesions  are  not  rare,  and  it  is  important  to 
remember  that  they  are  more  frequently  produced  by  kicks  from  horses.  In  23 
cases  the  small  intestine  was  injured  16  times,  and  the  small  and  large  intestine  7 
times.  In  the  149  cases  collected  the  mesentery  was  torn  in  11.  Bouley  reports 
a  case  in  which  the  rupture  of  the  intestine  was  inch  long,  and  Lentz  one  in 
which  it  was  4|  inches  long  ;  14  cases  of  complete  isolation  are  reported  ;  of  the 
duodenum  1  ;  junction  of  the  duodenum  and  jejunum  3 ;  ileo-jejunal  10.  Com- 
plete section  of  the  large  intestine  has  not  been  observed,  very  probably  by  reason 
of  its  anatomical  nature,  its  size,  and  its  ordinary  state  of  distension  by  gas.  As 
regards  the  frequency  with  which  different  portions  of  the  small  intestine  are 
injured,  Chavasse  classes  them  as  follows  :  1.  Small  intestine — middle,  superior, 
and  inferior  thirds  ;  2.  Colon ;  3.  Duodenum  ;  4.  Caecum  ;  5.  Sigmoid  flexure. 
On  account  of  its  length  the  ileo-jejunal  portion  is  injured  six  times  as  often  as 
the  other  portions  It  is  curious  to  note  that  two  cases  of  abdominal  injury  have 
been  reported  in  which  the  lesions  were  limited  to  the  peritoneum. 

The  question  of  the  mechanism  of  ruptures  of  the  intestine  by  these  injuries 
has  been  variously  interpreted  by  authors.  J obert,  Forget,  Baudens,  and  Legouest 
recognize  no  other  method  than  that  of  compressing  the  intestine  between  the 
vertebral  column  and  the  impacting  body.  Longuet  has  shown  experimentally 
that  this  explanation  is  perfectly  justifiable.  Farsavant  reports  a  case  in  which 
three  irregular  perforations  were  made  in  the  transverse  colon  by  a  blow  from  a 
large  stone.  In  his  work  on  internal  pathology,  Duplay  gives  three  methods  by 
which  rupture  maybe  produced:  1.  Direct  compression  against  the  vertebral 
column;  2.  Forcing  of  the  intestinal  contents  from  within  outwards;  3.  Com- 
pression of  the  intestinal  wall  between  the  injuring  body  and  the  matters  con 
tained  in  the  cavity  of  the  viscus.  Of  these  the  former  is  most  probably  the  true 
explanation. 

As  would  be  expected,  the  principal  symptoms  are  due  to  peritoneal  reflex ; 
sharp  localized  pain,  repeated  vomiting  and  purging  ;  regularly  progressive  shock, 
and  tendency  to  collapse  ;  the  face  is  pale ;  the  extremities  are  cold ;  the  tem- 
perature febrile,  and  oscillating  about  the  normal,  contrasting  with  the  small, 
rapid  pulse,  and  anxious  and  accelerated  respiration.  Peritonitis  may  or  may 
not  be  developed  early.  It  is  necessary,  in  making  a  diagnosis,  to  eliminate 
lesions  of  other  abdominal  organs.  If  the  liver  is  injured  there  will  be  a  sensation 
of  weight  in  the  right  hypochondrium  ;  the  pain,  which  is  generally  localized  in 
this  region,  often  radiates  around  the  body,  towards  the  xyphoid  cartilage,  or  to 
the  shoulder.  If  the  gall-bladder  is  injured  or  ruptured,  it  will  be  shown  by  the 
presence  of  bile  in  the  vomited  matters.  Lesions  of  the  stomach  will  be  shown 
by  blood  in  the  vomited  matters  from  the  beginning.  The  presence  of  blood  in 
the  urine  and  the  amount  of  urine  in  the  bladder  will  usually  enable  the  surgeon 
to  know  if  the  kidneys  or  bladder  are  injured.  Tchudnovski  gives  as  a  sign  of 
intestinal  rupture  an  amphoric  souffle  in  the  right  hypochondrium,  the  lung  being 
uninjured.  This  symptom  is  not  more  valuable  than  the  following,  given  by 
Spaggia.  In  auscultating  the  lateral  abdominal  and  lumbar  wall,  one  hears,  in 
cases  of  rupture,  a  gurgling  bruit  caused  by  the  inspiratory  and  expiratory  move- 
ments, displacing  the  fecal  and  gaseous  matters  in  the  abdominal  cavity.  The 
presence  of  blood  in  the  stools  is  a  positive  indication  of  a  serious  lesion ;  but  it 
is  rarely  seen  (four  times  in  147  cases),  as  marked  constipation  is  almost  always 
present.  The  existence  of  hernia  at  the  time  of  the  injury  may  cause  a  serious 
error  in  diagnosis. 

The  prognosis  in  a  case  of  this  kind  should  be  very  reserved.    The  mortality 
in  the  149  collected  cases  was  96  per  cent.,  death  having  occurred  most  frequently 
No.  CLXXVII.— Jan.  1885.  18 


274 


Progress  of  the  Medical  Sciences. 


[Jan. 


between  the  twelve  and  twenty-four  hours.  On  account  of  the  high  rate  of  mor- 
tality of  ruptures  treated  by  the  ordinary  means,  the  surgeon  should  not  hesitate 
to  perform  laparotomy,  and  search  for  the  injury.  Whether  a  simple  suture  be 
placed  in  the  intestinal  wall,  or  the  intestine  be  resected,  or  an  artificial  anus  be 
made,  must  depend  upon  the  extent  of  the  injury  and  the  judgment  of  the  sur- 
geon.— Archives  de  M6d.  et  de  Pharm.  MiliL,  Nos.  13,  14,  15,  1884. 

Excision  of  a  Piece  of  Intestine. 

Dr.  Joseph  Grindon,  of  St.  Louis,  reports  the  case  of  a  woman  who  received 
a  stab- wound  in  the  left  groin,  parallel  to  Poupart's  ligament  and  about  an  inch 
above  it.  Through  this  opening  there  had  protruded  a  mass  of  small  intestine, 
mesentery,  and  omentum.  There  had  passed  out  probably  between  six  and  eight 
feet  of  intestine.  In  one  of  the  foremost  loops  were  to  be  seen  three  cuts  or  tears, 
all  communicating  with  the  lumen  of  the  gut,  and  close  to  the  mesenteric  junction. 
Two  were  on  one  side  not  quite  two  inches  apart,  and  one  on  the  other,  as  it 
were  behind  and  between  the  first  two.  It  seemed  as  though  all  three  had  been 
done  at  one  thrust,  the  instrument  passing  in  at  one  side,  nicking  the  opposite 
wall,  and  passing  out  again  on  the  same  side  of  the  bowel  as  it  penetrated.  The 
largest  of  these  openings  easily  admitted  the  finger,  the  other  two  being  much 
smaller,  but  through  all  there  oozed  blood  and  fluid  feces.  The  condition  of 
things  here  met  with  agreed  with  the  observations  of  Dr.  Parkes,  of  Chicago,  in 
his  recent  experiments  on  dogs.  He  says,  "  Extravasation  of  the  contents  of  the 
tube  occurred  in  every  case  where  the  tube  was  wounded  ;"  and  again,  "any 
perforation  of  the  bowel,  even  a  needle  perforation,  means  extravasation." 
These  cuts  were  not  clean  incisions,  but  contused,  lacerated  wounds,  presenting 
the  appearance  of  having  been  inflicted  with  a  dull  weapon. 

It  was  at  first  proposed  to  throw  ligatures  about  the  wounds.  The  number  and 
extent  of  the  latter,  however,  would  have  made  this  manoeuvre  result  in  too  great 
a  narrowing  of  the  lumen ;  on  the  other  hand,  the  ragged  character  of  the 
wounds,  and  the  contused  and  ecchymosed  appearance  of  the  surrounding  tissue 
did  not  encourage  us  in  essaying  to  stitch  the  edges  together.  We  therefore 
proceeded  to  remove  a  section  of  the  gut  about  two  inches  in  length  comprising 
the  entire  circumference  and  including  all  the  injured  portion.  In  tiimming  off* 
along  the  mesenteric  border,  a  number  of  vessels  were  necessarily  cut  and  tied. 
There  was  considerable  eversion  of  the  mucous  membrane  at  each  severed  end ; 
this  was  trimmed  off*  with  the  scissors,  and  the  gut  brought  together.  Twelve 
or  fifteen  sutures  of  ordinary  surgeon's  silk  were  used ;  the  needle  being  each 
time  carried  through  all  the  coats  in  each  direction.  An  interrupted  stitch  was 
put  in  at  the  mesenteric  border,  one  directly  opposite,  and  one  half-way  down 
on  each  side  ;  between  these  was  run  a  glover's  suture.  The  free  mesenteric 
edge  was  merely  doubled  over  and  left  so. 

The  intestines  were  now  well  sponged  off*  with  clean  water,  no  antiseptics  ot 
any  kind  being  used,  and  returned  to  the  cavity  of  the  abdomen.  The  omentum 
slipped  back  without  much  trouble,  but  reducing  the  intestine,  distended  with 
gas  from  the  removal  of  accustomed  pressure  and  relaxation  of  the  muscular  tunic, 
proved  to  be  no  easy  task.  As  one  loop  would  be  forced  in,  another  would  slip 
out.  By  slightly  enlarging  the  opening,  however,  and  making  continuous  and 
equable  pressure  with  the  extended  hand  while  the  patient  was  brought  partially 
under  the  influence  of  chloroform,  and  the  thighs  flexed,  the  reduction  was  finally 
accomplished,  the  last  loops  being  livid,  intensely  congested,  and  of  most  for- 
bidding appearance.  The  external  wound  was  closed  with  a  stout  piece  of  silk 
passed  through  the  entire  thickness  of  the  abdominal  wall,  a  compress  applied, 


1885.] 


Surgery. 


275 


and  the  patient  dispatched  to  the  city  hospital.    During  the  operation  she  had 
received  two  dram  doses  of  laudanum.  The  patient  left  the  hospital  in  six  weeks. 
The  points  to  which  attention  is  called  are  :  — 

1.  The  use  of  no  antiseptic  or  germicide,  except  water.  The  surroundings 
were  all  of  an  unfavorable  nature,  the  work  being  done  in  a  back  kitchen.  It 
was  a  very  hot  day,  and  the  patient  lay  next  to  a  hot  stove. 

2.  The  fact  of  the  woman's  being  in  the  puerperal  condition  not  interfering 
with  the  successful  issue  of  the  case.  Her  former  pregnancies,  extending  over  a 
period  of  six  years  of  married  life,  had  resulted  as  follows,  given  in  the  order  of 
their  occurrence:  A  miscarriage  at  eight  months  (?)  ;  one  at  five  months;  a 
birth  at  term ;  a  miscarriage  at  seven  months,  one  at  five  months,  and  one  at 
four. 

3 .  The  carrying  of  the  sutures  into  the  calibre  of  the  gut,  and  not  leaving  the 
mucous  lining  untouched  as  recommended  by  Parkes  and  others.  The  mucous 
membrane  which  rolled  out  was  trimmed  off",  as  has  been  stated,  still  it  is  highly 
probable  that  at  one  or  more  points,  portions  of  this  surface  were  brought  into 
apposition  with  each  other. 

The  question  might  be  asked,  why  excise  at  all,  why  not  merely  stitch  up  the 
wounds  ?  I  have  already  spoken  of  the  unpromising  look  of  the  cut  edges,  but  I 
may  again  quote  Parkes.  In  his  experiments,  "  when  several  wounds  occurred 
close  together,  one  piece,  even  if  it  amounted  to  ten  inches,  was  removed;"  and 
again,  "wounds  affecting  the  mesenteric  border  of  the  bowel  were  always  the 
most  serious,  and  always  required  complete  resection  of  the  part  affected."  And 
again,  "  when  several  wounds  occur,  say  within  four  inches  apart,  make  one  re- 
section to  cover  the  whole." 

Another  interesting  question  regards  the  final  disposition  of  the  sutures.  What 
became  of  them,  or  where  did  they  go  ?  Miller,  Erichsen,  Druitt,  Holmes, 
Gross,  Ashhurst,  and  the  weight  of  evidence  teach  that  they  pass  into  the  bowel, 
and  are  so  cast  out.  I  cannot  do  better  than  to  quote  again  from  Mr.  Pollock  : 
"This  much,  therefore,  is  evident:  first,  that  soon  after  the  application  of  a 
ligature  or  suture  to  any  portion  of  intestine,  fibrin  is  effused  on  its  surface,  and 
the  ligature  becomes  thus  shut  out  from  the  peritoneal  sac.  Secondly,  the  liga- 
ture equally  soon  commences  to  destroy  that  portion  of  bowel  which  is  surrounded 
by  the  silk.  Thirdly,  that  as  the  mucous  membrane  (forming  one  of  the  layers 
of  that  portion)  dies  or  ulcerates,  it  opens  inwards  a  path  of  escape  for  the  liga- 
ture, which  is  only  complete  when  each  coat  of  the  bit  of  intestine  is  entirely 
cut  through  ;  and,  fourthly,  that  this  path  opens  into  the  bowel,  not  from  it." — 
St.  Louis  Courier  of  Med.,  Oct.  1884. 

Prolapse  of  the  Omentum  through  the  Rectum. 

Dr.  Domenico  Morisani  reports  the  rare  and  interesting  case  of  a  woman, 
about  thirty-nine  years  of  age,  who  came  under  his  observation  in  April,  1884. 
A  few  months  before  coming  under  observation  she  noticed,  after  going  to  stool, 
that  something  had  come  down  into  the  anus.  About  a  month  after  this  she  had 
an  attack  of  intestinal  catarrh,  of  a  somewhat  dysenteric  form,  and  after  a  severe 
straining  noticed  that  something  was  violently  expelled  from  the  rectum ;  this  in- 
creased after  each  effort  at  defecation. 

On  examination  it  was  seen  that  the  anal  orifice  was  greatly  dilated,  and  that 
from  it  was  a  projection  about  twelve  inches  long.  It  was  rigid,  and  described, 
to  a  certain  degree,  the  arc  of  a  circle.  Its  surface  was  knotty,  and  formed  of  a 
series  of  lumps,  resembling  the  configuration  of  the  transverse  portion  of  the 
colon.    The  external  surface  was  epithelial.    On  a  straining  effort  being  made  it 


276 


Progress  of  the  Medical  Sciences. 


[Jan. 


projected  about  four-fifths  of  an  inch  further  than  usual,  and  returned  -with 
the  straining.  It  was  also  seen  that  the  recto-vaginal  partition  had  become 
ulcerated  through,  and  a  great  part  of  the  feces  was  passed  through  the  vulval 
orifice. 

The  following  operation  was  performed  under  strict  antiseptic  precautions. 
The  tumor  was  pulled  down,  and  it  was  observed  that  there  was  a  fold  of  mucous 
membrane  closely  unired  to  it.  On  attempting  to  insert  a  tent  between  the  fold 
and  the  tumor,  the  tent  passed  into  a  cavity.  It  was  then  drawn  out,  and  the 
blade  of  a  probe-pointed  bistoury  inserted  :  the  blade  was  then  turned  vertically 
against  the  fold  of  mucous  membrane  so  as  to  nick  it  in  several  places.  Traction 
was  again  performed,  and  the  drawn-out  portion  was  at  once  thought  to  be  a  part 
of  the  great  omentum.  The  finger  was  then  introduced  along  the  tumor  and 
found  to  be  in  the  abdominal  cavity.  It  was  also  ascertained  that  the  tumor  had 
come  down  from  the  abdominal  cavity  by  perforating  the  intestine. 

Being  convinced  that  the  tumor  should  be  removed,  Morisam  drew  down  from 
the  abdomen  the  other  portion  of  the  omentum.  Four  points  of  the  Spencer 
TV  ells'  chain  suture  were  then  placed  in  the  part  drawn  out,  and  afterwards 
tightened  by  crossing  it  in  the  omental  tissue.  About  three-fifths  of  an  inch 
below  this  ligature  the  tumor  was  cut  off.  and  the  pedicle  dressed  with  iodoform 
and  returned  to  the  abdominal  cavity.  The  opening  in  the  intestine  was  then 
plugged  with  an  antiseptic  sponge,  its  edges  freshened  and  stitched  to  the  rectal 
mucous  membrane.  A  second  set  of  vertical  sutures  was  then  put  in.  and  the 
whole  wound  dressed  antiseptically.  The  patient  died  of  septic  peritonitis  on  the 
sixth  day. 

The  autopsy,  made  thirty  hours  after  death,  showed  a  collection  of  pus  in  the 
pelvis,  a  small  opening  in  the  intestine,  through  which  feces  had  extravasated. 
and  the  contents  of  the  abdominal  cavity  agglutinated.  There  was  considerable 
lengthening  of  the  transverse  mesocolon.  The  stomach  was  in  its  normal  posi- 
tion, but  the  transverse  colon  was  dislocated,  being  curved  so  as  to  form  a  sort  of 
angle,  the  apex  of  which  was  in  the  pelvic  cavity.  The  epiploica  magna  had 
entered  an  opening  in  the  wall  of  the  prolapsed  colon  and  had  gradually  passed 
out  per  anum.  There  was  nothing  to  show  clearly  how  the  perforation  was 
caused. — Rivista  Internazionale  di  Med.  e  Chir.,  No.  7,  1884. 

Retroperitoneal  Hernia,  due  to  Arrest  of  Intestinal  Development. 
This  case,  which  is  reported  by  Dr.  Carl  M.  Fubst,  of  Stockholm,  was 
seen  in  1881.  in  the  anatomical  amphitheatre  in  the  Caroline  Institute,  in  the 
cadaver  of  a  tailor,  aged  61  years.  The  body  had  been  found  in  Lake  Malar, 
where  it  had  been  for  half  a  day.  There  was  no  means  of  discovering  whether 
or  not  the  deceased  had  felt  any  inconvenience  from  his  internal  hernia  during 
ife. 

On  opening  the  abdominal  cavity  the  entire  colon  was  found  on  the  left  side, 
the  ca?cum  being  situated  perpendicularly  in  the  middle  line.  The  small  intes- 
tine was  on  the  right  side  and  directed  downwards.  About  two-thirds  of  the 
small  intestine  were  covered  and  inclosed  in  a  peritoneal  pouch  on  the  right  side, 
the  pouch  occupying  the  entire  right  lumbar  region,  and  the  adjacent  portions 
of  the  right  hypochondrium  and  of  the  umbilical  region.  This  pouch  was  large 
enough  to  contain  the  two  fists,  and  its  mouth  was  directed  downwards,  forwards, 
and  slightly  to  the  right,  its  greatest  diameter  measuring  12  cm.  It  was  limited 
by  the  free  border  of  the  peritoneal  fold,  the  left  cornu  of  which  was  divided 
into  two  folds,  the  one,  more  marked,  extending  to  the  mesenteric  connection  of 
the  appendix  vermiformis.  the  other  disappearing  in  the  mesentery  of  the  small 
jntestine  at  the  level  of  the  fourth  lumbar  vertebra.    The  right  cornu.  falciform. 


1885.] 


Surgery. 


277 


was  at  first  directed  backwards,  then  descended  to  the  left  over  the  lower  part  of 
the  kidney  and  disappeared  in  the  right  fold  of  the  mesentery  of  the  small  intes- 
tine ;  the  latter  escaping  from  the  pouch  by  a  simple  free  convolution.  The 
stomach  was  normal,  but  the  duodenum  was  directed  in  a  zigzag  manner  to  the 
right  by  three  parallel  convolutions. 

At  the  level  of  the  second  lumbar  vertebra  the  intestine  was  crossed  by  the 
attached  upper  border  of  the  peritoneal  fold  already  spoken  of,  and  entered  the 
upper  part  of  the  pouch  at  the  duodeno-jejunal  fold.  It  then  received  a  mesentery, 
the  attachment  of  which  extended  from  the  middle  of  the  second  lumbar  vertebra, 
downward  and  to  the  right,  to  the  right  side  of  the  promontory  ;  from  this  point 
to  the  lower  border  of  the  fourth  lumbar  vertebra,  to  the  left  of  the  median  line, 
then  passed  to  the  right  after  a  short  turn,  and  descended  into  the  mesocolon, 
which  extended  to  the  left  flexure  of  the  colon.  The  fold  of  the  caecum  was 
situated  in  the  middle  line,  and  the  ascending  colon  mounted  vertically.  Thence 
this  last  viscus  turned,  at  the  height  of  10  cm.,  horizontally  to  the  left,  described 
a  descending  convolution  until  it  reached  the  sigmoid  flexure,  when  it  mounted  to 
the  left  flexure  of  the  colon  and  again  took  its  normal  position.  The  ascending 
colon  was  inclosed  in  the  above-mentioned  peritoneal  fold,  and  had  what  may 
be  termed  a  double  mesentery,  one,  which  formed  the  left  wall,  inclosing  the 
vessels  and  mesenteric  glands,  the  other  only  cellular  tissue.  The  epiploon  was 
twisted  and  irregular. 

There  was  no  abnormality  of  any  of  the  other  viscera. 

Fiirst  is  of  the  opinion  that  the  position  of  the  intestine  was  the  effect  of  an 
arrest  of  development  dependent  on  an  anomaly  of  the  suspensory  ligament  of 
the  duodenum,  this  view  being  supported  by  the  zigzag  direction  of  the  duode- 
num. He  adopts  Gruber's  explanation  of  the  arrest  of  development  (Bildung- 
shemmung)  of  the  mesentery,  and  cites  several  cases  mentioned  by  Chiene, 
Clason,  and  Tscherning. 

The  explanation  of  the  origin  of  the  hernia  is  based  in  part  on  the  descriptions 
given  by  Preitz  of  the  embryonic  conditions  conducing  to  torsion  of  the  intestine. 
At  the  same  time  Fiirst  criticizes  Wa ldeyer's  argument  against  the  explanation 
given  by  Preitz  of  the  fixation  of  the  ascending  and  descending  colon,  which  is 
due  to  the  fact  that  the  anterior  abdominal  wall  requires  the  mesocolic  peri- 
toneum on  account  of  its  growth,  whilst  Waldeyer  asserts  that  the  mesenteric 
folds  are  in  no  way  required  for  parietal  coverings,  but  that  the  cause  of  the 
shortening  of  the  mesocolon  should  be  sought  in  the  growth  of  the  kidneys. 
Fiirst  thinks  that  the  difference  in  the  explanations  given  by  Preitz  and  Wald- 
eyer consists  in  the  fact  that  according  to  the  latter  it  is  the  middle  fold,  and 
according  to  the  first  the  lateral  fold  of  the  mesocolon  which  is  required. 

The  origin  of  the  hernia  is  due  to  the  fact  that  the  caecum,  which,  at  the 
beginning  of  the  third  month  of  foetal  life,  is  situated  in  the  middle  line  and  high 
up  under  the  liver,  is  prevented  from  passing  to  the  right  by  the  free  small  intes- 
tine. The  lateral  peritoneal  fold  of  the  mesocolon  exerts,  by  the  growth  of  the 
abdominal  wall,  strong  tension  on  the  lower  fixed  part  of  the  duodenum.  In  this 
way  a  sort  of  peritoneal  fold  is  formed  by  the  descent  of  the  caecum  while  grow- 
ing. This  fold,  the  concavity  of  which  was  directed  downwards,  covered  a  por- 
tion of  the  small  intestine,  and  finally  caused  hernia  after  the  intestines  were  filled 
with  food  and  gas.  The  dilating  force  exerted  by  the  intestines  on  the  peritoneal 
pouch  caused  the  caecum  and  ascending  colon  to  assume  a  vertical  position. 

Fiirst  thinks  this  the  more  simple  and  probable  explanation  of  the  anomalous 
condition  of  things  found  in  this  case:  The  superior  posterior  attachment  of 
the  pocket  passed  over  the  lower  part  of  the  duodenum,  whilst  the  free  border 
of  the  hernial  opening  passed  towards  the  caecum,  in  the  small  mesentery  of  the 


278 


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[Jan. 


vermiform  appendix  ;  and  finally,  that  a  simple  intestinal  convolution  passed  out 
of  the  hernial  opening,  and  the  ascending  colon  was  found  between  the  leaves  of 
the  peritoneal  fold.  The  fixation  of  the  mesentery  of  the  lower  portion  of  the 
ileum,  which  ascends  and  then  descends,  drawing  it  to  the  right  and  passing  into 
the  mesocolon,  is  a  strong  argument  in  favor  of  a  more  recent  descent  of  the 
cascum. — Nordiskt  Medicinskt  Arkiv.  Bd.  xvi.  Hft.  15 

The  After- Treatment  of  Lithotomy  when  the  Bladder  is  Sacculated  or  Pouched. 

In  a  paper  on  this  subject,  in  the  Lancet,  Nov.  8,  1884,  Mr.  Reginald 
Harrison  says  that  sacculation  or  pouching  of  the  bladder  is  not  only  a  frequent 
cause  of  stone  in  adults,  but  is  probably  the  most  serious  complication  attending 
its  removal.  An  ill-shapen  bladder  often  renders  lithotrity  out  of  the  question, 
whilst  it  increases  both  the  dangers  of  lithotomy  and  the  liability  to  a  recurrence 
of  stone.  A  careful  study  of  the  results  of  lithotomy  in  adults  not  only  shows 
them  to  be  unsatisfactory  when  compared  with  the  immediate  risks  of  the 
operation,  but  also  seems  to  point  to  certain  defects  in  the  after-treatment  to 
which  it  is  desirable  to  direct  attention.  To  remove  a  calculus  out  of  a  pouch  or 
depression  in  the  bladder,  and  not  at  the  same  time  to  provide  against  urine 
lodging  in  the  cavity  thus  formed  for  its  reception  and  decomposition,  is  to  incur 
a  risk  of  cystitis  and  septicaemia  which  is  by  no  means  an  imaginary  one.  It 
must  be  remembered  that  a  saccule  has  no  power  of  expelling  its  contents  ;  its 
walls  contain  no  muscular  fibre,  and  it  is  entirely  dependent  on  its  relation  to 
the  general  cavity  of  the  bladder  for  the  emptying  of  whatever  it  may  contain. 
The  small  mortality  following  lithotomy  in  children  and  the  extraction  of  stone 
in  women  is  largely  due  to  the  fact  that  the  conditions  in  both  are  favorable  to 
the  thorough  drainage  of  the  bladder. 

I  have  recently  been  adopting  a  system  of  drainage  after  lithotomy  and  other 
cases  in  which  the  bladder  has  been  opened  which  has  so  far  proved  a  great  benefit. 
In  the  first  place,  in  all  instances  of  stone  complicated  with  a  large  prostate  and 
with  saccules  on  a  depressed  floor,  I  have  been  particularly  careful  by  a  sufficient 
division  of  the  prostate  to  make  a  free  access  to  the  bladder ;  this  has  sometimes 
necessitated  the  section  of  the  gland  to  a  greater  extent  than  was  requisite  for  the 
removal  of  the  calculus. 

To  provide  free  drainage  after  the  operation  for  all  depressed  portions  of  the 
bladder,  the  following  plan  has  been  adopted  (it  is  practically  that  of  the  double 
tube  in  tracheotomy)  :  Through  an  ordinary  lithotomy  tube  open  at  the  end  is 
passed  and  retained  a  rubber  catheter,  or  drainage-tube  ;  this  adapts  itself  to  the 
inequalities  in  the  walls  of  the  bladder,  and  can  be  made  to  enter  any  saccule  that 
may  be  present.  In  a  recent  case,  though  the  ordinary  lithotomy  tube  seemed 
to  be  draining  efficiently,  I  had  from  the  general  symptoms  reason  to  believe 
that  some  urine  was  retained.  On  introducing  the  rubber  catheter  in  the  manner 
described,  several  ounces  of  fetid  urine  escaped,  after  which  the  progress  of  the 
case  was  good.  By  the  double  tube  a  constant  system  of  drainage  is  carried  on, 
so  that  urine  escapes  immediately  on  entering  the  bladder. 

I  would  remark  that  to  rapidly  heal  up  a  bladder  which  in  its  mechanical  con- 
struction has  all  the  elements  necessary  for  the  production  of  calculus  is  not  in 
my  judgment  a  wise  proceeding,  as  long  as  anything  can  be  gained  by  not  doing 
so. 

In  cases  of  calculus  associated  with  residual  urine  and  a  large  prostate,  I  have 
had  some  excellent  results  in  cases  in  which  it  was  deemed  desirable  to  retain 
the  lithotomy  tube  for  considerable  periods  of  time — partly  for  the  purpose  of 


1885.] 


Surgery. 


279 


draining  and  partly  with  the  view  of  bringing  about  a  permanently  improved  con- 
dition in  the  outlet  from  the  bladder — namely,  cases  in  which  the  tube  has  been 
retained  for  six,  eight,  or  even  ten  weeks. 

The  advantages  of  the  double  tube  after  lithotomy  performed  under  the  cir- 
cumstances mentioned  may  be  summarized  as  follows  : — 

1.  The  prevention  of  vesical  colic  and  spasm  by  retention  of  clots  and  the 
plugging  of  the  ordinary  tube  with  blood. 

2.  The  more  perfect  drainage  of  the  floor  of  the  bladder,  however  irregular 
this  surface  may  be. 

3.  A  ready  mode  of  washing  out  all  parts  of  the  bladder  without  removal  of 
the  outer  tube.  For  the  latter  purpose,  one  of  Tiemann's  double  current  rubber 
catheters,  fitted  on  to  a  Higginson's  syringe  and  passed  through  the  ordinary 
lithotomy  tube,  answers  admirably. 

4.  Increased  facilities  for  keeping  the  patient  dry,  by  having  the  inner  tube 
sufficiently  long  to  conduct  the  urine  into  a  vessel  by  the  patient's  bedside  ;  the 
bed  may  be  kept  absolutely  dry  until  the  time  comes  for  the  removal  of  the  tube 
altogether.  This  is  a  point  of  great  importance,  especially  in  elderly  persons, 
who  are  liable  to  bedsores  and  suffer  much  from  the  immediate  presence  of 
ammoniacal  urine. 

The  tenesmus  and  pain  at  the  end  of  the  penis  which  are  sometimes  caused, 
where  the  prostate  is  large,  by  the  retention  of  thick  ropy  mucus  on  the  floor  of 
the  bladder  are  considerably  mitigated  by  this  plan,  combined  with  the  free  use 
of  some  solvent  for  this  secretion.  The  best  solvent  for  vesical  mucus  I  have  yet 
found  is  a  solution  of  common  salt  in  warm  water,  with  which  the  bladder  should 
be  washed  out  by  the  double  tube  as  described,  as  often  as  necessary.  In  all 
cases  of  this  kind  the  tubes  should  be  retained  and  drainage  employed  until  the 
urine  shows  that  it  can  pass  through  the  bladder  without  undergoing  decom- 
position in  it ;  as  long  as  there  is  any  sign  of  the  latter,  there  is  a  risk  of  the  re- 
formation of  stone.  A  considerable  number  of  the  softer  stones  are  entirely  of 
vesical  origin.  The  prevention  of  these  necessarily  brings  under  consideration 
the  remedying  of  the  causes  upon  which  they  depend.  These  latter  are  not 
always  difficult  to  discover. — Lancet,  Nov.  8,  1884. 

Iodoform  in  Soft  Chancres. 

Unna  (Monats.  fur  prakt.  Dermatologie,  August,  1884)  finds  that  for  the 
present  no  remedy  heals  the  soft  chancre  more  rapidly  than  iodoform,  and  none 
with  such  certainty  obviates  the  occurrence  of  a  suppurating  bubo.  The  draw- 
back is  the  peculiar  and  suggestive  odor  which  no  combination  serves  entirely  or 
permanently  to  mask.  One  cause  of  the  diffusion  of  the  odor  is  the  custom  of 
employing  iodoform  in  powder  ;  too  much,  more  than  necessary  is  thus  applied, 
and  the  powder  is  apt  to  be  deposited  on  the  clothes  during  or  after  application. 
He  therefore  advises  that  iodoform  dissolved  in  ether  be  used.  The  sore  is  first 
dried  with  absorbent  cotton,  then  a  drop  of  the  iodoform  ether  allowed  to  fall  on 
the  sore,  and  the  evaporation  of  the  ether  favored  by  blowing  on  it  with  a  hand- 
ball bellows.  Thus  a  thin  coating  of  iodoform  is  deposited  exactly  on  the  ulcer. 
Over  the  ulcer  so  coated  he  places  a  small  piece  of  perforated  iodoform  plaster 
muslin,  which  has  been  brought  to  perfection  as  regards  its  preparation  by  Beiers- 
dorf,  of  Altona.  If  this  appears  too  thin,  a  circular  band  of  the  same  can  be  wound 
round  the  penis,  or  a  strip  applied  if  the  ulcer  is  seated  elsewhere  Lastly,  to 
conceal  the  smell,  a  piece  of  cotton-wool,  perfumed  by  means  of  a  spirituous 
solution  of  cumarin,  is  placed  over  all.    If  desirable,  this  wool  can  be  sprayed 


280 


Progress  of  the  Medical  Sciences. 


[Jan. 


over  with  some  volatile  aromatic  fluid.    When  the  ulcer  occurs  in  the  meatus 
urinarius,  he  supplies  the  patient  with  a  pencil  of  iodoform  composed  as  follows  : — 
I£— Iodoformi  .       .       .  .10.0 

Gummi  Arabici  .       .  .3.0 

Gummi  Tragacanthse  .       .  1.0 

Glycerini    .       .       .       .  1.0 

Aq.  q.  suff.  M.  Fiat  bacilli,  N.  5. 

These  are  kept  in  a  little  wooden  box.  After  voiding  urine,  the  pencil,  made 
pointed,  is  dipped  in  water  and  several  times  introduced  with  a  screwing  motion 
into  the  meatus.  A  small  piece  of  the  perfumed  wool  is  now  passed  in  between 
the  lips,  and  a  larger  piece  wrapped  round  the  glans.  Unna  further  remarks  that 
these  pencils  serve  as  valuable  prophylactics  against  infection  from  gonorrhoea  or 
soft  sore. — Edinb.  Med.  Journ.,  Dec.  1884. 

The  Treatment  of  Perforating  Ulcer  of  the  Foot. 
In  an  article  on  this  subject,  Mr.  Frederick  Treves  draws  attention  to  the 
following  plan  of  treatment,  which,  in  the  two  cases  in  which  I  have  as  yet  tried 
it,  may  be  considered  to  have  met  with  a  degree  of  success.  On  examining  these 
ulcers  it  is  obvious  that  the  dense  rigid  ring  of  heaped-up  epithelium  that  sur- 
rounds the  sore  or  sinus  forms  a  very  grave  bar  to  healing.  The  ulcer  could 
never  heal  as  long  as  its  margin  is  set  in  an  annular  induration  that  prevents  an 
approximation  of  its  edges  and  an  opportunity  for  the  display  of  the  healing  pro- 
cess. Even  if  the  ulcer  were  to  become  filled  up  with  granulations  its  final  closure 
would  still  be  a  matter  of  considerable  difficulty,  since  the  skin,  that  takes  so 
active  a  share  in  the  healing  of  such  lesions,  would  be  seriously  hampered  in  its 
activity.  The  plan  alluded  to  is  this  :  The  patient  is  confined  to  bed  and  the 
sole  of  the  foot  is  kept  continuously  poulticed  with  linseed  meal.  This  causes  the 
epithelium  to  soften  and  swell  up,  so  that  at  the  end  of  twenty-four  hours  the 
ring  around  the  sore  appears  as  a  very  prominent  softish  white  mound.  All  this 
redundant  epidermis  is  then  shaved  away  with  a  scalpel,  and  the  poultice  is  reap- 
plied. At  the  end  of  another  twenty-four  hours  the  deeper  layers  of  epithelium 
that  were  not  affected  by  the  first  poulticing  have  become  swollen  and  prominent. 
They  are  in  turn  cut  away.  The  poultice  is  again  applied  and  the  scalpel  used 
day  by  day,  until  the  whole  of  the  epidermic  mass  has  been  removed.  This  ob- 
ject will  be  effected  at  the  end  of  about  ten  or  fourteen  days.  By  this  time  the 
skin  about  the  ulcer  will,  as  a  result  of  the  continued  poulticing,  have  peeled  off 
in  a  thick  white  layer,  and  around  the  sore  will  be  nothing  but  thin  fresh  pink 
epidermis,  looking  active  and  healthy.  The  ulcer  in  the  mean  time  will  be 
found  to  have  cleaned,  and  by  the  loss  of  its  cutaneous  boundary  will  appear  less 
deep.  The  poultices  are  now  discontinued,  and  to  the  sore  is  applied  a  paste,  of 
the  consistence  of  thick  cream,  composed  of  salicylic  acid  and  glycerine,  to  which 
is  added  some  carbolic  acid  in  the  proportion  of  ten  minims  to  the  ounce.  This 
paste  is  applied  on  lint,  and  is  quite  painless.  The  ulcer  soon  heals,  and  when  the 
patient  gets  up  he  is  instructed  to  wear  a  thick  pad  of  felt  plaster  over  the  spot, 
with  a  hole  in  its  centre  that  corresponds  to  the  scar  of  the  recent  sore.  This 
plaster  should  be  always  worn.  As  one  objection  to  this  measure  it  may  be  urged 
that,  although  pressure  may  be  taken  off  on  one  part  of  the  sole,  an  ulcer  may 
appear  at  some  other  spot  where  pressure  has  effect.  As  far  as  my  two  cases  go, 
this  result  has  not  yet  happened  ;  and  it  is  to  be  noted  that,  although  a  large  area 
of  the  sole  is  normally  exposed  to  pressure,  these  ulcers  have  a  tendency  to  appear 
only  in  certain  spots.  The  patients  should  also  be  instructed  to  pay  great  atten- 
tion to  the  cleanliness  of  the  feet,  to  wear  well-fitting  woollen  stockings  and  easy 
boots. — Lancet,  November  29,  1884. 


1885.] 


Surgery. 


281 


Excision  of  the  Head  of  the  Femur  for  Spontaneous  Dislocation. 

At  the  meeting  of  the  Koyal  Medical  and  Chirurgical  Society,  on  October  28, 
Mr.  William  Adams  contributed  an  example  of  spontaneous  dislocation  of  the 
head  of  the  femur  on  the  dorsum  ilii,  occurring  during  the  progress  of  rheumatic 
fever,  in  a  boy  eleven  years  of  age.  The  patient  was  admitted  into  the  Great 
Northern  Hospital  on  the  4th  March,  1882.  After  two  unsuccessful  attempts  at 
reduction,  having  previously  divided  the  adductor  longus  tendon,  he  had  excised 
the  head  of  the  femur  on  the  29th  March,  making  a  \-shaped  incision  with  the 
long  arm  two  and  a  half  inches  in  length  directly  over  the  head  and  neck  of  the 
bone :  and  the  small  arm,  one  inch  in  length,  transversely  over  the  head  of  the 
bone,  which  was  at  once  exposed  uncovered  by  capsular  ligament,  and  the 
articular  cartilage  in  a  healthy  condition.  It  was  found  that  the  capsular  liga- 
ment had  been  ruptured,  and  the  torn  margins  of  the  rent  passed  on  either  side 
of,  and  closely  embraced,  the  neck  of  the  bone.  After  dividing  the  margins  of 
the  capsular  ligament  he  passed  his  small  subcutaneous  saw  to  the  neck  of  the 
bone,  and  cut  through  it  a  little  below  the  margin  of  the  articular  cartilage.  The 
detached  head  of  the  femur  was  then  drawn  out  of  its  position  after  some  slight 
adhesions  had  been  cut  through.  The  round  ligament  preserved  its  normal  con- 
nection with  the  head  of  the  bone,  and  was  adherent  to  the  articular  cartilage, 
having  been  divided  with  the  saw  a  little  below  the  head.  The  wound  progressed 
favorably  without  much  suppuration,  and  on  the  1st  June  was  completely  closed. 
On  the  14th  June  the  patient  was  allowed  to  walk  on  crutches,  and  on  the  1st  Octo- 
ber without  crutches.  The  limb  was  perfectly  straight,  and  the  movement  at  the 
hip-joint  freely  permitted  in  all  directions.  The  author  observed  that  in  all  the 
cases  of  spontaneous  dislocation  which  had  fallen  under  his  observation  the  head 
of  the  femur  had  been  dislocated  on  to  the  dorsum  ilii.  These  he  arranged  in 
three  classes  :  (1)  Dislocation  occurring  during  the  progress  of  fever.  (2)  Dis- 
location occurring  in  cases  of  paralysis,  generally  infantile,  but  occasionally  in  the 
adult.  (3)  Dislocation  occurring  in  the  first  stage  of  hip-joint  disease  without 
suppuration.  Excision  of  the  head  of  the  femur  in  its  simplified  form  as  above 
described  the  author  believed  would  be  found  applicable  to  all  these  cases,  unless 
sufficient  freedom  of  motion  be  obtained  by  tenotomy  and  passive  movements. 
He  also  thought  it  might  be  applicable  to  some  cases  of  fibrous  anchylosis  of  the 
hip  after  disease  when  the  limb  remained  contracted,  as  free  motion  was  seldom 
obtained  by  simply  dividing  the  neck  of  the  bone.  The  cases  of  dislocation  of 
the  hip  brought  before  the  Society  by  Mr.  Morris  were  alluded  to,  and  also  the 
cases  published  in  St.  Thomas's  Hospital  Reports,  by  Sir  William  MacCormac, 
in  which  he  excised  the  head,  neck,  and  great  trochanter  in  a  case  of  unreduced 
traumatic  dislocation  of  the  hip  into  the  thyroid  foramen.  The  firm  adhesions, 
and,  in  some  cases,  new  bone  thrown  out  in  cases  of  traumatic  origin  as  the  result 
of  the  inflammation  following  the  injury,  the  author  observed,  distinguished  these 
cases  from  cases  of  spontaneous  dislocation  occurring  during  the  progress  of  fever, 
or  in  cases  of  paralysis  which  had  chiefly  fallen  under  his  observation. — Medical 
Times  and  Gazette,  November  1,  1884. 

Resection  of  the  Knee. 
In  a  recent  contribution  (Mitiheilungen  aus  der  Chirurgischen  Klinih  zu 
Tubingen,  1884)  on  resection  of  the  knee  in  cases  of  fungous  disease,  Prof. 
Bruns  states  that  of  late  he  has  attained  much  better  results  from  this  opera- 
tion in  consequence  of  certain  improvements  in  its  performance,  in  the  dressing 
of  the  wound,  and  in  the  after-treatment.    In  nineteen  out  of  twenty  cases  in 


282 


Progress  of  the  Medical  Science 


[Jan. 


which,  during  twelve  months,  the  knee  was  excised  for  tubercular  disease,  the 
wounds  healed  by  primary  intention  under  the  first  dressing.  Formerly,  it  is 
pointed  out,  the  chief  object  in  resection  of  this  joint  was  to  remove  the  whole  of 
the  deceased  bone.  Since,  however,  fungous  articular  disease  has  been  regarded 
as  an  articular  tuberculosis,  and  this  view  has  been  confirmed  by  the  discovery  of 
the  tubercle-bacillus  in  the  granulations  of  the  synovial  membrane  and  of  the 
articular  extremities  of  the  bones,  more  and  more  attention  has  been  directed  in 
the  operation  to  a  careful  extirpation  of  the  granular  synovial  membrane.  In 
each  of  the  above-mentioned  cases  as  much  care  was  taken  in  removing  all  the 
diseased  tissues,  both  within  and  without  the  joint,  as  would  have  been  done  in 
the  extirpation  of  a  malignant  growth.  Not  only  the  fungous  articular  synovial 
membrane,  but  also  the  synovial  pouch  communicating  with  the  joint,  especially 
the  subcrural  mucous  sac,  was  completely  removed  by  the  use  of  the  knife  and 
scissors.  Moreover,  the  peri-articular  tissues,  as  fascice,  ligaments,  and  muscles, 
whenever  diseased,  were,  together  with  the  capsule,  carefully  removed.  Peri- 
articular abscesses  were  also  extirpated,  and  abscesses  reaching  upwards  on  to 
the  thigh  were  slit  up  along  their  extent,  and  the  abscess-membrane  of  each  was 
not  merely  scraped  away  with  a  sharp  spoon,  but  was  extirpated  in  toto.  Pro- 
fessor Bruns  takes  away  the  patella  and  also  the  ligamentum  patella?,  the  pos- 
terior surface  of  which  is  closely  connected  with  the  capsule  and  a  pouch  of  the 
articular  synovial  membrane.  The  dissection  should  be  carried  on  until  healthy 
structures  are  exposed,  and  until  finally,  in  front  of  the  articular  ends  of  the 
long  bones,  all  the  soft  parts  between  the  skin  and  the  bones  are  removed.  Not- 
withstanding the  great  extent  of  the  wound,  primary  healing  always  takes  place, 
as  only  healthy  tissues  are  left,  and  all  parts  that  might  include  the  existing 
agents  of  inflammation  are  carefully  removed.  The  great  danger  of  relapse  after 
excision  of  a  tubercular  joint  is  known  to  most  surgeons,  and  has  been  proved  by 
Konig's  tables  of  117  cases.  In  most  instances,  the  relapse  is  due  to  the  reten- 
tion of  tubercular  deposits  in  the  soft  parts.  In  the  knee-joint,  the  anatomical 
conditions  are  such  as  to  favor  a  radical  extirpation. 

Prof.  Bruns  holds  that  it  is  necessary  to  remove  the  patella  in  almost  every 
case  of  fungous  disease.  The  retention  of  this  bone  complicates  the  healing  of 
the  wound,  renders  difficult  complete  removal  of  the  synovial  membrane,  and 
increases  the  risks  of  relapse.  An  exception  to  this  rule  is  made  in  some  cases 
of  resection  of  the  knee  in  children,  In  consequence  of  the  very  probable 
dangers  of  arrest  in  the  subsequent  growth  of  the  limb  after  resection  on  young 
subjects,  it  is  necessary  to  remove  as  little  of  the  bone  as  possible,  and  to  en- 
deavor to  perform  only  a  partial  operation.  If  most  or  every  part  of  the  articular 
cartilages  be  left  intact,  the  patella  must  be  retained,  as  the  patient  will  very 
probably  recover  with  a  movable  joint. 

Prof.  Bruns  states  that  in  some  cases  the  most  suitable  mode  of  incision  is 
that  known  as  the  inferior  curved  excision,  which  is  carried  across  the  front  of  the 
joint  and  through  the  ligamentum  patella?,  so  as  to  form  a  superior  flap.  In  the 
majority  of  cases,  however,  of  fungous  disease  of  the  knee,  the  superior  curved 
excision,  recently  advocated  by  Hahn,  will,  it  is  held,  be  found  the  most  con- 
venient. This  incision  forms  an  arch  with  the  convexity  directed  upwards,  and 
is  made  through  the  tendon  of  the  quadriceps  muscle.  The  flap  thus  formed, 
which  contains  the  patella,  is  turned  downwards,  and  the  upper  recess  of  the 
joint  is  at  once  freely  exposed.  When  this  recess  is  much  diseased  and  extends 
far  upwards  in  front  of  the  thigh,  the  superior  curved  incision  is  by  far  the  best. 
Much  importance  is  attached  to  this  recess,  as  being  almost  constantly  involved 
in  fungous  disease,  and  as  being  the  starting-point  of  relapse  after  resection. 
Another  advantage  of  the  superior  curved  incision,  Prof.  Bruns  points  out,  is 


1885.] 


Ophthalmology  and  Otology. 


283 


that  the  wound  in  the  soft  parts  is  not  in  the  same  line  with  that  in  the  bones, 
and  that  the  cleft  between  the  same  surfaces  of  the  femur  and  tibia  is  covered  by 
the  flap,  and  not  so  much  exposed,  as  in  the  usual  operation,  to  external  influ- 
ences. In  ten  of  the  twenty  recent  cases  of  resection  of  the  knee,  Prof.  Bruns 
made  the  superior  curved  incision,  in  nine  cases  the  inferior  curved  incision,  and 
in  the  remaining  three  the  patella  was  sawn  across  obliquely  and  then  removed. 
In  each  case  dressings  of  corrosive  sublimate  were  applied,  the  ends  of  the  bones 
were  kept  in  contact  by  two  nails,  and  the  edges  of  the  flap  were  brought  together 
by  sutures  applied  as  carefully  as  in  a  plastic  operation  on  the  face.  The  limb, 
having  been  inclosed  in  "wood-wool,"  was  then  put  up  in  a  Watson's  splint 
and  plaster-of-Paris  bandage. — London  Medical  Record,  Oct.  15,  1884. 


OPHTHALMOLOGY  AND  OTOLOGY. 

Cocaine  as  an  Ancesihetic  in  Ophthalmic  Practice. 
At  the  meeting  of  the  Society  of  Physicians  of  Vienna,  on  October  17,  Dr.  Karl 
Roller  read  a  paper  on  this  subject.  The  anaesthetic  influence  which  cocaine  exerts 
when  applied  locally  to  the  mucous  membrane  of  the  tongue  led  Dr.  Koller  to  try  its 
effect  on  the  eye.  After  referring  to  the  publications  of  Schroff,  Anrep,  and  Freud, 
he  made  several  experiments  on  animals  in  Professor  Strieker's  laboratory,  from 
which  he  found  that  two  or  three  drops  of  a  two  per  cent,  aqueous  solution  of  chlo- 
ride of  cocaine,  introduced  into  the  conjunctival  sac,  rendered  the  cornea  and  con- 
junctiva quite  insensible.  If  he  scratched  with  a  needle,  or  even  perforated  the  cor- 
nea of  animals  so  treated,  or  passed  a  strong  electrical  current  through  it  or  touched 
it  with  caustic,  the  animals  felt  no  irritation  at  all.  As  to  the  duration  of  this  anaes- 
thesia, he  could  obtain  no  idea  from  his  experiments  on  animals.  He  tried  to  find 
out  if  cocaine  had  also  an  influence  on  the  inflamed  cornea.  He  first  produced 
keratitis  in  animals  by  introducing  a  foreign  body  into  the  eye,  and  he  found  that 
the  cocaine  also  acted  as  a  local  anaesthetic  under  these  conditions.  The  success  of 
these  experiments  on  animals  led  him  to  try  the  effect  of  cocaine  on  the  human 
eye,  and  he  had  obtained  the  following  results :  (1)  One  or  two  minutes  after 
introducing  a  few  drops  of  a  two  percent,  solution  of  cocaine  chloride,  the  cornea 
and  conjunctiva  were  rendered  completely  insensible  ;  he  could  seize  the  conjunc- 
tiva with  hooked  tweezers  and  exert  considerable  pressure  on  the  cornea,  and  the 
patient  felt  nothing,  nor  were  there  any  reflex  movements.  The  anaesthesia 
lasted  from  seven  to  ten  minutes,  and  disappeared  gradually.  (2)  Simulta- 
neously with  the  anaesthesia,  considerable  dilatation  of  the  palpebral  orifice 
occurred,  which  he  explained  by  the  absence  of  the  sources  of  irritation  which 
otherwise  affect  the  cornea  and  conjunctiva.  (3)  The  ocular  and  palpebral  con- 
junctiva became  anaemic.  (4)  Fifteen  minutes  after  introduction,  mydriasis  set 
in.  It  was  never  present  in  any  great  degree ;  after  an  hour  it  decreased  con- 
siderably, and  totally  disappeared  some  hours  later.  During  this  period  the 
pupil  reacted  quickly.  (5)  Paresis  of  accommodation  set  in  together  with  the 
mydriasis,  and  also  disappeared  with  it.  (6)  When  the  application  of  the  above- 
mentioned  solution  of  cocaine  chloride  was  continued,  and  repeated  every  five 
minutes,  the  anaesthesia  of  the  cornea  lasted  from  fifteen  to  twenty  minutes,  and 
the  deeper  parts  of  the  eyeball  became  anaesthetic,  its  sensibility  being  much 


284  Progress  of  the  Medical  Sciences.  [Jan. 

diminished  on  pressure.  (7)  The  application  of  cocaine  never  produced  any 
signs  of  irritation.  Dr.  Roller  had  further  made  therapeutic  experiments  with 
cocaine  in  Professor  v.  Reuss's  clinic,  and  found  that  it  was  a  good  anodyne  in 
diseases  of  the  eye  which  were  associated  with  pain.  He  obtained  good  results 
with  it  in  various  diseases  of  the  cornea  and  conjunctiva,  which  were  associated 
with  pain  and  photophobia,  as,  e.  g.,  syndesmitis  lymphatica  and  erosions  of  the 
cornea ;  it  was  also  of  use  in  cases  in  which  the  touching  of  the  eyelids  with 
nitrate  of  silver  would  cause  severe  pain.  He  recommended  the  application  of 
cocaine  in  cases  of  iritis  and  iridocyclitis  where  the  contraction  of  the  vessels  must 
render  good  service.  The  application  of  cocaine  as  an  anaesthetic  in  ophthalmic 
operations  had  excellent  results  in  thirty  cases  of  removal  of  foreign  bodies  from 
the  cornea,  in  cases  of  tattooing  cicatrices  on  the  cornea,  in  two  cases  of  operation 
for  staphyloma  in  children,  as  well  as  in  several  iridectomies  and  operations  for 
cataract.  When  the  ansesthesia  in  these  operations  was  produced  according  to 
the  method  which  Roller  had  recommended,  i.  e.,  with  a  five  per  cent,  solution, 
the  patients  stated  that  they  felt  nothing  of  the  corneo- scleral  incision,  while  the 
seizing  and  excision  of  the  iris  caused  them  but  little  pain.  In  this  respect  he 
quoted  an  interesting  case  in  which  iridectomy  was  performed  on  a  man  who  had 
suffered  from  "  seclusio  pupillaa,"  affecting  both  eyes;  the  solution  was  applied 
in  the  operation  on  one  eye  and  omitted  when  the  other  eye  was  operated  on  a 
week  later.  The  patient  declared  he  felt  no  pain  at  all  during  the  first  opera- 
tion, but  his  restlessness  during  the  second  operation  rendered  it  difficult. — Med. 
Times  and  Gazette,  November  8,  1884. 

Chiselling  of  the  Mastoid  Process. 

Dr.  Arthur  Hartmann  reports  14  cases  of  chiselling  of  the  mastoid  process, 
with  1 2  recoveries  and  2  deaths.  He  gives  a  short  general  review  of  his  practical 
experience,  as  follows  :  — 

The  incision  of  the  skin  and  the  opening  of  the  bone  should  be  practised  at  the 
line  of  attachment  of  the  auricle,  or,  at  least,  immediately  behind  it. 

In  two  cases  of  the  entire  number  the  operation  was  performed  on  the  healthy 
surface  of  the  mastoid  process.  In  both  cases  the  skin  incision  was  made  at  the 
line  of  attachment  of  the  auricle,  and  the  mastoid  was  opened  directly  beneath 
this.  In  both  cases  the  collection  of  pus  was  reached  at  a  trifling  depth.  In  the 
other  cases  with  formation  of  fistules  it  likewise  proved  most  judicious  so  to 
incise  the  skin  that  the  bone  beneath  the  line  of  attachment  of  the  auricle,  or 
immediately  behind  it,  should  come  into  the  region  attacked  by  the  chisel.  It 
did  not  seem  advisable  to  carry  the  operation-canal  further  backward  on  account 
of  the  danger  of  injuring  the  transverse  sinus.  According  to  the  results  of  exam- 
inations of  the  cadaver  already  communicated,  and  which  are  essentially  in 
accord  with  those  of  Bezold  and  others,  a  sharp  forward  curve  of  the  transverse 
sinus  toward  the  posterior  wall  of  the  auditory  canal  is  very  frequent.  In  100 
temporal  bones,  the  shortest  distance  between  the  sigmoid  fossa  and  the  posterior 
wall  of  the  auditory  canal  amounted  in  41  cases  to  1  cm.  or  less,  in  1  case  to 
5  mm.,  in  5  cases  to  6  mm.,  and  in  6  cases  to  7  mm.  The  average  distance  was 
11.5  mm.,  the  maximum  19  mm.  The  danger  of  wounding  the  transverse  sinus 
is  best  seen  on  horizontal  sections.  As  we  cannot  foretell  whether  we  shall,  in 
operating,  chance  upon  a  sharp  curve  of  the  transverse  sinus,  such  a  possibility 
should  always  be  borne  in  mind.  Those  who  are  familiar  with  the  anatomical 
relations  of  the  parts  will,  therefore,  avoid  the  use  of  drills  or  trephines,  such  as 
are  employed  by  many  physicians.    When,  in  using  such  an  instrument,  the  sinus 


1885.] 


Ophthalmology  and  Otology. 


285 


is  chanced  upon,  an  injury  to  it  is  inevitable,  whereas,  in  the  operation  with  the 
chisel,  as  the  ground  is  kept  clear  for  inspection,  we  can  recognize  the  danger  in 
time  and  avoid  it.  In  the  operation,  special  attention  should  be  paid  to  the  fact 
that  the  more  the  sinus  projects  forward,  so  much  the  nearer  does  it  approach 
the  external  surface  of  the  bone.  Accordingly  when  a  sinus  is  markedly  curved 
forward  we  reach  it  at  a  trifling  depth. 

As  for  the  danger  of  penetrating  into  the  middle  cranial  fossa,  he  holds  to  the 
principle  previously  laid  down,  that  the  operation-canal  should  not  extend  higher 
than  the  level  of  the  upper  wall  of  the  auditory  canal.  Anatomical  investigations 
have  shown  that  the  floor  of  the  middle  cranial  fossa  is  not  infrequently  separated 
from  the  upper  wall  of  the  auditory  canal  by  only  a  thin  long  lamella,  and  lies 
but  a  little  above  it,  which  state  of  affairs  he  has  described  as  the  low  position 
(Tiefstand)  of  the  middle  cranial  fossa.  In  operating  on  the  cadaver  after  the 
manner  of  Buck  (Arch,  of  Ophthal.  and  Otol.,  vol.  iii.  p.  212),  who  sets  the 
drill  a  little  above  the  line  of  the  external  canal  and  penetrates  inward,  and  a 
little  upward  and  forward,  he  penetrated  the  middle  cranial  fossa  with  the  drill 
in  three  cases  out  of  one  hundred.  In  operating,  the  skin  incision  and  the  bony 
canal  should  be  made  so  large  that  a  free  inspection  of  the  wound-cavity  may  be 
possible  during  the  after-treatment.  In  this  way  it  becomes  easy  to  remove 
pieces  of  bone  which  become  detached  later.  Moreover  we  can  (and  he  con- 
siders this  of  the  utmost  importance  for  a  complete  and  permanent  cure)  remove 
remaining  or  luxuriant  granulations  with  the  sharp  spoon  or  with  caustics.  In 
order  to  maintain  the  passage  open  for  after-treatment,  rubber  tubes  are  inserted 
immediately  after  the  operation,  to  be  replaced  later  by  thick,  and  still  later  by 
thin,  lead  ones.  These  lead  tubes  can  be  easily  prepared  by  rounding  one  end 
of  a  small  piece  of  tube  with  the  knife,  and  giving  to  the  other  end  a  funnel 
shape  by  splitting  it  and  bending  the  two  halves  apart.  The  advantage  of  the 
lead  tube  over  the  lead  nails  is,  that  through  the  former  the  secretions  can  pass, 
while  by  the  latter  their  discharge  is  impeded.  The  operation-canal  must  be 
kept  patent  until  such  time  as  the  wound-cavity  has  diminished  in  size  concen- 
trically, by  the  development  of  sound  granulations.  Soft  granulations  are  removed 
as  above  mentioned,  or  are  caused  to  shrink  by  cauterization  with  the  nitrate  of 
silver. 

For  complete  removal  of  old  retained  secretions  or  cholesteatomatous  masses 
in  the  mastoid  process,  we  find  it  impossible  in  many  cases  to  dispense  with  the 
inflexible  tympanum-tube,  which  he  has  recommended  for  cleansing  the  drum 
cavity  and  its  recesses.  To  prevent  inflammatory  reaction  after  the  operation, 
the  covering  of  the  walls  of  the  cavity,  and  of  the  canal  in  the  bone,  with  pow- 
dered iodoform  has  proved  of  most  avail.  In  none  of  the  operated  cases  did 
inflammatory  reaction  ensue.  With  the  existence  of  acute  symptoms  before  the 
operation,  there  followed  in  all  cases  an  immediate  recedence  of  the  symptoms 
and  a  surprisingly  rapid  cure,  which  he  thinks  should  be  attributed  to  the  em- 
ployment of  the  iodoform.1  Both  fatal  cases  may  be  excluded  from  consideration 
here,  as  in  these  the  operation  was  done  at  a  stage  of  the  disease  when  a  favor- 
able result  was  not  to  be  counted  on,  as  the  symptoms  of  cerebral  disease  had 
already  developed.    In  the  use  of  the  iodoform  there  is  a  circumstance  upon 


1  In  one  of  these  operated  cases,  a  patient  with  acute  inflammation  of  the  middle 
ear  and  involvement  of  the  mastoid  process,  the  mastoid  was  chiselled  open  on  Feb. 
10th,  the  perforation  of  the  drum  membrane  had  closed  on  the  13th,  the  lead  tube 
was  removed  on  the  18th,  and  on  the  23d,  the  patient,  at  his  own  request,  returned  to 
work  with  a  small  superficial  granulating  wound. 


286 


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[Jan. 


which,  possibly,  the  favorable  effect  of  the  remedy  depends — namely,  that  the 
iodoform  forms  with  the  underlying  tissues  a  soft,  firmly  attached  crust  ;  indeed, 
it  is  impossible  to  get  a  good  view  of  the  wound-cavity  until  after  some  days, 
when  the  crust  has  come  away  of  itself  or  has  been  removed  By  this  crust- 
formation,  on  account  of  the  scanty  secretion,  we  can  leave  the  first  dressing 
unchanged  for  two  or  three  days. 

When  we  consider,  on  the  one  hand,  that  the  artificial  opening  of  the  mastoid 
process  in  acute,  as  well  as  in  chronic,  diseases,  leads  to  a  prompt  and  perfect 
cure,  and  that  the  operation  must  be  regarded  as  entirely  free  from  danger ;  and, 
on  the  other  hand,  the  often  very  tedious,  incomplete  recoveries  accompanied 
with  severe  functional  disturbance  which  now  and  then  result  from  conservative 
treatment,  we  must  decide  in  favor  of  the  former  plan ;  so  much  the  more  as 
under  the  conservative  method  there  is  always  danger  during  its  course  of  the 
extension  of  the  disease  deep  into  the  mastoid.  Again,  in  the  chronic,  forms  we 
are  frequently  unable  to  decide  whether  or  not  sequestra  exist,  which  can  only 
be  removed  by  an  operative  procedure. — Archives  of  Otology,  vol.  xxii.  No.  2. 


MIDWIFERY  AND  GYNAECOLOGY. 

Craniotomy  in  Germany. 

Dr.  Adolph  Merkel  contributes  to  a  recent  number  of  the  Archiv  fur  Gyna- 
kologie  an  analysis  of  100  cases  of  craniotomy  occurring  in  the  Leipzig  clinic. 
Statistics  are  of  very  little  use  in  determining  questions  relating  to  this  operation, 
because  its  results  depend  almost  entirely  upon  the  personal  dexterity  of  the 
operator,  the  cases  in  which  the  operation  is  done,  and  the  time  at  which  it  is 
done.  An  obstetrician  who  recognizes  the  necessity  for  the  operation  early,  and 
therefore  does  not  waste  time  in  fruitlessly  attempting  delivery  by  other  methods, 
and  who  handles  his  instruments  skilfully,  ought  to  get  a  mortality,  as  far  as  the 
mother  is  concerned,  not  larger  than  that  of  ordinary  labor.  There  are,  how- 
ever, two  points  in  Dr.  Merkel' s  communication  worth  noting.  One  is,  that  his 
results  of  craniotomy  followed  by  cephalotripsy  are  better  than  those  in  which 
the  latter  operation  was  not  done.  The  other  is,  that  the  author  finds  the  scissor- 
shaped  perforator  (Levret's  is  the  form  he  uses)  better  than  the  trephine,  which 
is  so  commonly  used  in  Germany,  and  recommended  in  German  books.  The 
latter  discovery  English  practitioners  have  long  since  made  ;  and  we  doubt  not, 
that  if  they  will  try  the  English  perforators,  German  obstetricians  will  come  to 
agree  with  Dr.  Merkel — Med.  Times  and  Gaz.,  August  9,  1884. 

Separation  of  the  Symphysis  Pubis  daring  Labor. 

Dr.  E.  F.  Eldridge  reports  the  case  of  a  woman  who  had  been  unable  to 
walk  for  some  time  without  the  aid  of  two  canes.  On  examination  he  found 
her  pregnant,  at  nearly  full  term  ;  the  abdomen  was  enormously  distended,  the 
wall  of  the  vagina  relaxed  and  partially  prolapsed,  the  symphysis  pubis  was 
separated  three-quarters  of  an  inch,  and  the  bones  at  the  sacro-iliac  synchon 
drosis  quite  movable. 


1885.] 


Midwifery  and  Gynaecology. 


287 


She  said  that  the  inability  to  walk  had  gradually  come  on  ;  that  she  could  feel 
her  hips  move  up  and  down  when  she  stepped,  and  that  she  felt  as  though  she 
was  being  pried  apart.  At  her  confinement,  which  took  place  a  week  later,  the 
normal  pains  came  on,  and  the  contractions  were  strong  and  regular.  The  pre- 
sentation was  normal  and  in  the  first  position,  but  progress  was  slow,  the  labor 
lasting  seven  hours.  The  child  was  a  male,  weighing  ten  and  one-half  pounds, 
and  looked  as  though  it  was  at  least  a  month  old  ;  the  head  was  large,  the  fon- 
tanelles  nearly  closed,  and  the  skull  remarkably  osssified.  During  the  passage  of 
the  head  through  the  outlet  of  the  pelvis,  the  symphyses  separated  one  and  a 
quarter  inches,  so  that  two  fingers  could  be  passed  between  them. 

She  made  a  good  recovery,  the  bones  returned  to  their  normal  position,  and 
finally  united  as  firmly  as  before  ;  locomotion  is  perfect.  She  said  that  she  was 
troubled  in  the  same  way  at  her  last  confinement,  but  not  to  such  an  extent. — 
Chicago  Med.  Journ.  and  Exam.,  Dec.  1884. 

The  Value  of  Unilateral  Incisions  for  Preventing  Ruptures  of  the  Perineum. 
In  an  exhaustive  article  on  this  subject  Crede  and  Colpe,  after  studying  the 
subject  of  ruptures  of  the  perineum  in  regard  to  their  frequency  and  the  means 
for  preventing  them,  pronounce  themselves  decidedly  in  favor  of  the  unilateral 
.incision  ;  much  preferring  it  to  the  recommendation  of  some  authors  that  the  rup- 
ture be  allowed  to  occur,  after  which  it  may  be  cured  by  immediate  suturing. 

The  following  objections  have  been  made  to  the  lateral  incision  :  1.  It  may 
easily  lead  to  more  or  less  extensive  ulceration  after  delivery,  and  thus  retard 
recovery;  2.  The  wounds  resulting  from  the  incision  may  be  the  point  of  origin 
of  infection  ;  3.  The  incision  does  not  always  prevent  rupture  of  the  perineum  ; 
4.  However  small  the  incision  may  be,  the  operation  is  painful ;  5.  Finally,  the 
incisions  leave  traces,  and  may  favor,  up  to  a  certain  point,  occlusion  of  the 
vagina. 

In  reply  to  these  objections,  Crede  and  Colpe  give  the  following  statistics  from 
the  Leipzig  Maternity  Hospital,  showing  that  as  regards  the  numbers  of  perineal 
lesions  there  were,  in  1000  primiparse  cases,  392  ;  of  these,  there  were  259  lateral 
incisions,  or  25.9  per  cent.  ;  spontaneous  ruptures  104,  or  10.4  per  cent.  ;  rup- 
tures in  spite  of  incision  29,  or  2.9  percent.  Of  1000  multipara?  cases,  there  were 
12  lateral  incisions,  or  1.2  per  cent.  ;  spontaneous  ruptures  24,  or  2.4  per  cent. 
En  resume,  of  2000  cases  of  labor  there  were  271  lateral  incisions  or  13.5  per 
cent.  ;  ruptures  128,  or  6.4  per  cent.  ;  ruptures  in  spite  of  incision  29,  or  1.4  per 
cent.  As  regards  the  sequelas  of  these  2000  labors,  229  went  out  of  the  Maternity 
in  about  fifteen  days. 

As  regards  infection  the  dangers  of  the  lateral  incision  should  not  be  exagge- 
rated. Of  the  2000  cases  tabulated,  there  were  33  deaths,  19  being  due  to  infec- 
tion, the  remaining  14  to  puerperal  eclampsia,  ruptures  of  the  uterus,  and  inter- 
current diseases.  Besides  the  19  cases  of  septicemia,  of  1572  labors  with  intact 
perineum,  there  were  15  deaths ;  of  those  with  the  lateral  incision  there  were  4. 
It  is  rather  more  difficult  to  draw  any  definite  conclusions  as  to  the  infectious 
accidents  (non- mortal)  during  the  labors,  as  there  were  a  great  many  normal 
labors  in  these  cases  ;  but  it  is  quite  certain  that  the  lateral  incision  plays  no  part 
in  the  production  of  disease. 

As  regards  the  objection  that  the  lateral  incision  does  not  always  prevent  rup- 
ture, the  statistics  from  the  Leipzig  Maternity  show  that,  of  300  cases  of  episto- 
tomy,  there  were  29  ruptures  of  the  perineum,  or  9.6  per  cent.  But  it  should  be 
noted  that  in  25  of  these  cases  there  were  other  unfavorable  circumstances  ;  in  15 


288 


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cases  the  children  were  very  large  ;  and  of  the  15  cases  the  forceps  were  used  in  3 
cases  ;  there  was  1  case  of  faulty  engagement ;  and  4  of  granular  vaginitis.  In 
7  other  cases  in  which  the  children  were  not  of  large  size,  the  perineum  was 
weakened  by  syphilis  in  3  cases,  there  was  1  parietal  presentation,  1  case  of 
hydrocephalus,  and  in  2  cases  the  rupture  was  caused  by  the  shoulders.  And  in 
these  cases  there  was  not  one  of  total  rupture. 

As  regards  the  pain  of  the  incision,  it  is  scarcely  to  be  mentioned  in  comparison 
with  that  caused  by  the  contractions  of  the  uterus  and  the  pressure  of  the  head  on 
the  vulva.  Furthermore,  by  favoring  the  disengagement  of  the  foetal  head,  the 
incision  saves  the  woman  a  number  of  pains,  and  is  therefore  rather  indicated 
than  contraindicated. 

As  regards  the  ultimate  deformity  of  the  vulva  arising  from  the  cicatrix  conse- 
quent upon  the  incision,  the  authors  of  the  paper  state  that  Balandin  has  greatly 
exaggerated  the  inconveniences  in  saying  that  the  vulval  orifice  is  deformed,  that 
it  is  made  to  gape,  and  that  the  floor  of  the  pelvis  is  markedly  enfeebled.  This 
vulvar  insufficiency  never  reaches  the  degree  found  after  spontaneous  rupture, 
when  uncured  or  badly  cared  for. — Archives  de  Tocologie,  November,  1884. 

Hot  Uterine  Douches  in  Post-Par  turn  Hemorrhage. 

Dr.  Carl  Kegnault,  of  Stuttgart,  says,  in  an  article  on  this  subject,  that- 
since  the  contributions  of  Sclmlein,  and  especially  of  Richter,  as  to  the  results  of 
the  use  of  hot  intra-uterine  douches  in  post-partum  hemorrhage,  only  a  few  have 
been  found  who  have  raised  objections  to  them. 

Of  2398  cases  of  labor  at  the  Landeshebammenschule,  in  Stuttgart,  in  the  last 
five  years,  there  were  108  cases  (4.3  percent.)  in  which  hot  intra-uterine  douches 
were  used  post  par  turn ;  cold  intra-uterine  douches  were  not  used.  Of  the  108 
cases  there  were  80  of  hemorrhage ;  in  28  the  hot  douches  were  used  on  anti- 
septic grounds.  For  the  douches  two  quarts  of  a  1  or  2  per  cent,  carbolic  solu- 
tion at  117°  to  122°  Fahr.  In  those  cases  in  which  the  cervix  was  not  sufficiently 
large  to  allow  the  passage  of  a  glass  tube,  Fritsch's  catheters  were  used.  The 
return  of  the  injected  fluid  was  always  free  and  unhindered.  In  a  few  cases  a 
1  :  4000  solution  of  corrosive  sublimate  was  used.  In  no  case  were  these  symp- 
toms of  intoxication  from  the  disinfecting  agent,  whether  corrosive  sublimate  or 
carbolic  acid  was  used.  This  may  have  been  due  to  the  fact  that  the  injections 
were  seldom  repeated  ;  in  the  greater  number  of  cases,  especially  of  hemorrhage, 
only  one  injection  was  used. 

The  accompanying,  or  usually  previous  treatment  in  these  cases  was  the  use  of 
one  or  more  injections  of  ergotin  solution,  and  always  more  or  less  powerful 
kneading  of  the  uterus.  In  16  cases  in  which  hot  douches  were  used  for  a  slight 
or  medium  degree  of  hemorrhage,  no  ergotin  was  given.  In  3  of  these  cases 
blood-clots  or  a  bloody  flow  was  seen  in  the  same  afternoon,  after  the  use  of  the 
hot  douche,  and  in  3  others  on  the  2d,  3d,  and  4th  days.  Also,  one-third  of  all 
cases  of  after-bleeding  occurred  in  those  16  cases  treated  without  ergotin.  There 
were  also  4  cases  in  which  ergotin  alone  was  at  first  depended  on  to  arrest  fierce 
hemorrhage ;  but  it  was  found  that  the  hot  water  must  be  used.  These  4 
cases  very  well  illustrate  the  value  of  the  combined  treatment.  From  the  effect 
of  the  hot  douches  in  these  cases  it  may  be  concluded  that  the  contraction  of  the 
uterus  is  due  less  to  the  thermal  irritation  of  the  injection  than,  as  Richter  holds, 
to  an  cedematous  soaking-through  and  swelling  of  the  mucous  membrane  and 
submucous  tissue,  depending  on  the  inflammatory  irritation,  and  that  compres- 
sion of  the  bleeding  vessels  is  caused  by  the  accession  of  a  good  contraction  of  the 
uterus. 


1885.] 


Midwifery  and  Gynaecology. 


289 


The  indications  for  washing  out  the  cavity  of  the  uterus  are  of  two  kinds  : 
either  for  disinfecting  purposes,  or  for  controlling  hemorrhage.  In  a  consider- 
able number  of  cases  both  indications  are  present.  Injections  for  disinfection  are 
made  after  delivery  when  the  temperature  becomes  febrile,  in  cases  of  foul  liquor 
amnii  or  lochia,  in  cases  of  death  of  the  foetus  during  delivery,  and  on  prophy- 
lactic grounds  in  all  cases  in  which  examination  of  the  cavity  of  the  uterus  is 
demanded.  Injections  for  controlling  hemorrhage  are  made  in  cases  of  simple 
atony  of  the  uterus,  or  when  the  membranes  and  placenta  are  retained  ;  the  latter 
indications  do  not  often  occur.  In  such  cases  the  cavity  of  the  uterus  must  be 
thoroughly  cleaned  out,  except  in  cases  of  abortion,  when  the  narrowness  of  the 
cervix  prevents  the  introduction  of  the  hand. 

In  case  of  hemorrhage  in  the  late  days  of  childhood,  cold  douches  should  be 
used,  with  ergotin  subcutaneously  and  internally,  and  the  application  of  ice-bags. 

As  regards  the  results  of  the  hot  douche  treatment  of  hemorrhage,  it  is  worthy  of 
remark  that  in  none  of  the  80  cases  of  hemorrhage  was  there  any  considerable 
after-bleeding  :  of  these  80  cases  there  were  36  of  severe  hemorrhage  ;  and  there 
were  1 8  cases  in  which  it  was  very  slight,  6  of  which  were  treated  without  ergotin. 
These  cases  of  post-partum  hemorrhage  were  partly  of  fluid  blood,  partly  of  the 
passage  of  clots.  Two  cases  of  hemorrhage  occurred  on  the  12th  and  14th  days 
after  delivery,  the  others  usually  on  the  same  day,  or  within  the  first  six  days. 
As  regards  the  number  of  irrigations  necessary  in  any  case,  there  were  seven  cases 
in  which  a  second  douche  was  given  on  account  of  severe  atonic  hemorrhage.  The 
second  injections  were  made  ten  minutes  after  the  first  as  a  rule ;  in  one  case  one 
hour  after  the  first.  Richter  states  that  there  is  an  absence  of  blood  in  the  lochia 
after  the  use  of  the  hot  douches  ;  but  Regnault  cannot  confirm  this  from  his  own 
experience.  Richter  also  states  that  the  application  of  an  ice-bag  after  the  hot 
douching  predisposes  to  hemorrhage,  which  is  also  contrary  to  the  experience  of 
Regnault.  Another  good  result  of  the  hot  douche  is  the  increased  bodily  tem- 
perature which  follows  it,  the  early  improvement  in  the  state  of  the  pulse  and  of 
the  general  state.  And  it  is  noteworthy  that  Regnault  has  not  seen  a  single  case 
in  which  any  unfavorable  symptom  could  be  attributable  to  the  use  of  the  hot 
douche. — Centralbl.  fur  Gynakologie,  October  4,  1884. 

Diverticulum  of  the  Bladder  in  a  Woman;  Urethral  Ectasia  or  Vaginal 

Urethrocele. 

Professor  Carl  Santesson,  of  Stockholm,  describes  a  case  of  this  rare  affec- 
tion, which  he  treated  in  1861. 

The  patient,  set.  48  years,  had  twice  been  pregnant,  the  labors  being  very  dif- 
ficult, though  in  neither  case  were  instruments  used.  The  second  child  was  born 
twelve  years  before  she  presented  herself  for  treatment.  She  dated  her  trouble 
to  a  period  soon  after  the  second  labor.  The  first  symptoms  were  itching  and  a 
feeling  of  heat  in  the  vagina,  pain  in  the  vagina  on  coition,  and  whenever  she 
did  exhaustive  work ;  there  was  also  difficulty  in  micturition,  and  an  alternation 
of  retention  and  incontinence  of  urine. 

On  examination  the  anterior  vaginal  wall  was  found  depressed  at  the  vaginal 
orifice,  above  the  urethral  promontory  and  behind  the  urethra,  where  was  found 
a  smooth,  elastic  tumor,  as  large  as  a  nut.  There  was  nothing  else  abnormal 
about  the  vagina  or  uterus.  The  tumor  consisted  of  a  long  pouch,  about  lT2ff  inch 
long,  and  ^  inch  wide  ;  it  communicated  with  the  urethra  by  an  opening  situated 
at  the  junction  of  its  upper  and  middle  third,  which  was .  sufficiently  large  to 
admit  a  No.  16  sound.  Pressure  on  the  tumor  caused  no  urine  to  flow  out 
No.  CLXXVIL— Jan.  1885.  19 


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through  the  urethra  ;  the  urine  returned  to  the  bladder.  A  catheter  introduced 
along  the  anterior  wall  of  the  urethra  passed  into  the  bladder  without  difficulty. 
When  the  beak  of  the  catheter  was  turned  downwards,  it  went  into  the  pouch, 
and  could  not  be  introduced  further.  If  the  desire  to  micturate  was  not  imme- 
diately satisfied,  the  patient  was  unable  to  retain  her  urine  ;  it  escaped  involun- 
tarily, and  caused  considerable  pain.  The  urine  was  acid,  the  sp.  gr.  1.014, 
slightly  mixed  with  mucus,  but  contained  no  abnormal  matters. 

As  the  patient  could  not  then  submit  to  a  radical  operation,  Santesson  first 
used  the  silver  cautery  on  the  interior  of  the  urethra,  between  the  bladder  and 
the  pouch,  and  subsequently  cauterization  of  the  vaginal  surface  of  the  tumor 
with  fuming  nitric  acid,  and  thus,  by  making  an  eschar,  reduced  its  volume. 
This  treatment  gave  temporary  amelioration,  the  tumor  was  reduced,  and  there 
was  no  more  incontinence ;  the  patient  was  able  to  retain  her  urine  for  two  or 
three  hours  whilst  walking,  and  just  as  long  at  night. 

Three  years  and  a  half  later  she  returned  for  further  treatment,  the  old  trou- 
bles having  returned.  Santesson  excised  an  elliptical  piece  from  the  vaginal 
mucous  membrane  over  the  tumor,  and  united  the  borders  with  sutures.  A  part 
of  the  mucous  membrane  became  gangrenous,  but  the  cicatrix  was  so  much  larger 
and  more  resistant.  The  wound  was  completely  cured  in  about  five  weeks,  and 
the  cicatrix  looked  like  a  small  tumor  about  the  size  of  the  end  of  the  finger. 

Santesson  has  been  able  to  find  only  six  similar  cases  in  literature,  reported  by 
Foucher,  Gilette,  and  Duplay,  in  France ;  Priestley  and  Lawson  Tait,  in  Eng- 
land ;  and  G.  Simon,  in  Germany.  It  seems  very  improbable  that  the  affection 
is  so  extremely  rare ;  and  the  paucity  of  the  literature  would  seem  to  be  due  to 
the  fact  that  cases  are  overlooked.  As  regards  their  origin  and  etiology,  they 
may  be  classified  as  congenital  and  acquired  ectasia  ;  the  first  depending  on  a 
vicious  development,  as  when  the  vagina  opens  into  the  urethra,  and  being  obli- 
terated at  a  certain  distance  from  this  canal,  forms  a  diverticulum  communicating 
with  it ;  or  when  an  incomplete  development  of  the  urethra  gives  rise  to  a  greater 
or  less  solution  of  continuity  in  some  part  of  its  wall.  As  regards  the  varieties  of 
acquired  ectasia,  Santesson  draws  a  distinction  between  that  formed  by  partial 
dilatation  of  an  otherwise  normal  urethra,  and  without  solution  of  continuity ; 
and  those  due  to  the  fact  that  a  pre-existing  cavity  (as  open  abscess  or  cyst), 
situated  behind  the  urethra,  has  communicated  with  its  calibre.  To  the  first  he 
gives  the  name  diverticula  vera,  to  the  second  diverticula  spuria. 

The  diagnosis  must  depend  upon  a  most  careful  examination.  Santesson  con- 
siders the  plan  of  treatment  proposed  by  Foucher,  that  of  making  two  elliptical 
incisions  over  the  most  prominent  part  of  the  tumor,  as  the  best,  and  the  only 
one  which  is  rational.  This  operation  he  performed  in  the  case  reported.  The 
diverticulum  should  be  completely  opened,  and  the  edges  of  the  wound  closed 
with  sutures  over  a  catheter  introduced  into  the  urethra.  Care  should  be  taken, 
however,  that  the  external  and  internal  orifices  of  the  urethra  be  not  involved  in 
the  incision. — Nordiskt  Medicinskt  Arkiv,  Bd.  xvi.,  Hft.  4. 

The  Treatment  of  Retro- Uterine  Hcematocele. 
In  a  paper  published  in  a  recent  number  of  the  Archiv  fur  Gynakologie,  Dr. 
Paul  Zweifel  advocates  more  frequent  interference  with  these  effusions  than 
has  hitherto  been  considered  good  practice.  It  seems  to  us,  however,  that  the 
facts  he  adduces  do  not  strongly,  if  at  all,  support  his  contention.  He  advises 
incision  per  vaginam,  under  antiseptic  precautions,  followed  by  frequent  washing 
out  of  the  cavity  in  which  the  blood  has  been  contained.    He  relates £  our  cases 


1885.] 


Midwifery  and  Gynaecology. 


291 


of  his  own  in  which  this  practice  was  followed  ;  three  got  well  and  one  died.  He 
quotes  from  other  sources  24  cases  treated  by  incision  per  vaginam,  of  which  five 
died.  In  two  of  these  cases  death  occurred  by  sudden  collapse  following  the 
washing  out  which  Dr.  Zweifel  recommends.  As  he  thinks  the  washing  out  was 
not  done  in  these  cases  in  a  proper  manner,  our  author  eliminates  these  two,  and 
reckons,  including  his  own,  four  deaths  out  of  26  cases,  or  a  mortality  of  15.3  per 
cent.  In  our  view,  however,  the  two  omitted  cases  ought  by  all  means  to  be  lost 
sight  of,  for  they  prove  that  the  washing  out  of  such  cavities  is  not  a  thing  to  be 
done  with  perfect  confidence  in  its  safety.  Our  own  impression  is  that  most  cases 
do  just  as  well  without  it.  Dr.  Zweifel  then  adduces  a  collection  of  66  cases 
treated  by  puncture,  with  10  deaths,  or  15.1  per  cent.  ;  a  result  much  the  same 
as  that  gained  by  the  practice  of  incision.  Bearing  in  mind  the  fatal  cases  of 
injection,  puncture  seems  to  be  the  safer  practice.  Lastly,  Dr.  Zweifel  gives  for 
comparison  a  collection  of  129  published  cases  treated  on  the  expectant  plan,  with 
a  mortality  of  18.4  per  cent.  But  it  must  be  remembered  that  published  cases 
available  for  comparison  contain  an  undue  proportion  of  fatal  cases,  and  of  cases 
in  which  the  hematocele  discharged  into  a  mucous  tract ;  for  it  is  only  in  such 
cases  that  (independently  of  treatment)  the  diagnosis  is  certain.  It  is  familiar 
to  every  gynecologist  that  small  pelvic  tumors,  accompanied  with  the  history 
and  having  the  signs  of  hematocele,  are  very  common,  and  generally  get  soon 
well,  the  mortality  among  such  cases  (of  which  the  diagnosis,  although  not  scien- 
tifically certain,  is  yet  as  sure  as  that  of  the  cases  calling  for  operation)  being 
nothing  like  18  per  cent.  We  regard  Dr.  Zweifel's  figures,  combined  with  daily 
experience,  as  confirming  the  old  rule,  not  to  meddle  with  hematoceles  unless 
urgent  symptoms,  either  of  pressure  or  pyrexia,  are  present.  We  agree  with  him 
that,  if  we  do  anything  at  all,  a  free  incision  is  best ;  but  the  subsequent  washing 
out  adds  a  new  source  of  danger,  and,  if  free  exit  for  discharge  be  maintained  by 
a  drainage-tube,  is  not  required.  If  an  India-rubber  tube  will  not  keep  open,  a 
glass  one  can  be  used. — Med.  Times  and  Gazette,  November  8,  1884. 

Myomotomy. 

In  a  paper  on  this  subject,  read  in  the  Gynecological  Section  of  the  Eighth 
International  Medical  Congress,  Martin,  of  Berlin,  said  that  the  symptoms 
which  indicate  a  more  or  less  active  treatment  of  uterine  myomata  are  hemor- 
rhage, symptoms  of  pressure  on  the  neighboring  pelvic  organs,  disposition  of  the 
mucous  membrane  covering  the  myoma  towards  malignant  degeneration,  circu- 
latory disturbances,  and  heart- weakness.  He  has  used  ergotin  in  many  cases, 
and  is  very  much  pleased  with  the  results.  He  has  performed  castration  in  five 
cases,  and  had  favorable  results,  as  has  Wiedow,  in  the  Freiburg  clinic.  He 
finds,  however,  that  the  operation  for  the  removal  of  myomata  may  be  performed 
per  vaginam  ;  this  is  a  difficult  method  unless  the  myoma  has  a  polypous  develop- 
ment, but  it  is  not  a  dangerous  operation.  Martin  has  operated  ten  times  for 
myoma  of  the  uterine  wall,  and  twice  for  myoma  of  the  cervix.  Of  the  first  ten 
cases  eight  recovered ;  one  died  of  sepsis,  the  second  of  hemorrhage. 

Martin  recognizes  that  laparotomy  is  much  the  easiest  of  the  operations.  He 
has  performed  laparotomy  14  times  for  subserous  myomata;  2  died  of  sepsis, 
and  1  of  collapse  ;  1  from  septic  degeneration  of  the  myoma,  and  2,  very  anemic, 
of  collapse.  He  has  removed  large  myomata  per  vaginam  33  times.  The  first  6 
died  of  septic  infection  from  incomplete  antisepsis  ;  of  the  succeeding  seven  only 
2  died  of  sepsis,  1  of  these  being  anemic.  In  the  remaining  20  drainage 
through  Douglas's  pouch  was  made;  of  these  1  died  of  embolism,  2  on  account 


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[Jan. 


of  too  long  delay  in  operating,  and  3  of  sepsis ;  1  of  the  latter  from  degeneration 
of  the  myoma.  The  supra- vaginal  operation  was  performed  5  times  on  account 
of  carcinoma  and  sarcoma  ;  5  operations  were  performed  for  subserous  intraliga- 
mentous myomata ;  1  death  from  sepsis,  1  from  collapse.  Martin  declares  that 
if  the  operation  is  performed  in  the  course  of  symptomatic  treatment,  it  should 
be  performed  as  soon  as  possible.  The  greatest  danger  in  the  operation  is  from 
septic  infection,  especially  during  the  period  of  convalescence.  On  this  account 
he  strongly  advises  drainage  through  Douglas's  pouch. 

Lowenthal  recommended  the  old  method  of  incising  the  anterior  wall  in 
intraperitoneal  myomata  in  order  to  reach  the  seat  of  development.  He  has 
recently  performed  this  operation  in  two  cases. 

Winchel  asked  Martin  as  to  his  views  of  the  ergotin  treatment.  He  himself 
thinks  that  it  must  be  given  for  some  time,  and  in  large  doses.  As  to  the  indi- 
cations for  laparotomy,  he  thinks  that  no  hard  and  fast  line  can  be  drawn. 

Fehling  has  used  ergotin  very  extensively,  but  he  is  now  more  careful  with 
this  drug,  since  he  has  seen  degeneration  of  the  myoma  in  two  cases  under  its 
use.  He  regards  it  as  of  especial  value  in  cases  of  rapidly  growing  cavernous 
myomata,  which  increase  at  the  menstrual  periods. 

Hofmeier  said  that  the  prognosis  of  the  operations  depends,  to  a  considerable 
extent,  on  the  anatomical  situation  of  the  tumor.  The  prognosis  is  very  favorable 
if  the  uterine  cavity  be  not  opened.  Of  20  cases  he  has  had  only  1  prove  fatal. 
Of  35  cases,  in  which  the  cavity  of  the  uterus  was  opened,  8  died.  Subserous 
development  of  the  tumors  makes  the  prognosis  much  graver;  of  21  such  cases 
12  died.  He  thinks  that  to  prevent  sepsis  the  cervix  should  be  energetically 
disinfected,  and  its  mucous  membrane  deeply  incised. — Centralbl.  fur  Gynak., 
October  18,  1884. 

Intrauterine  Medication. 
At  the  close  of  an  introduction  to  a  discussion  in  the  section  of  obstetric  medi- 
cine at  the  fifty-second  annual  meeting  of  the  British  Medical  Association,  Dr. 
Lombe  Atthill  drew  the  following  conclusions:  — 

1.  Carbolic  acid,  in  the  proportion  of  one  part  of  spirit  to  two  of  the  acid,  is 
the  safest  and  most  generally  useful  of  all  the  agents  employed. 

2.  Carbolic  acid  should  always  be  applied  by  means  of  a  probe,  round  the 
point  of  which  a  layer  of  cotton  is  rolled,  the  cotton  being  carried  up  to  the 
fundus  at  least  twice  on  each  occasion  that  the  applications  are  made,  which 
should  be  on  every  third  or  fourth  day,  till  marked  improvement  takes  place. 

3.  Carbolic  acid  should  never  be  injected  into  the  uterus,  except  when  com- 
bined with  iodine,  in  the  form  known  as  iodized  phenol. 

4.  In  many  cases,  iodized  phenol  may  with  advantage  be  applied  by  means  of 
a  probe. 

5.  In  cases  in  which  metrorrhagia  or  profuse  menstruation  occurs,  depending 
on  an  unhealthy  condition  of  the  intrauterine  mucous  membrane,  the  cavity  being 
dilated  and  the  uterus  enlarged,  from  half  a  drachm  to  a  drachm  of  iodized 
phenol  may  be  injected  with  great  advantage. 

6.  In  cases  in  which  epithelioma  attacks  the  mucous  membrane  of  the  cavity, 
the  injection  of  iodized  phenol  promises  better  results  than  any  other  treatment. 

7.  The  success  likely  to  follow  the  injection  of  iodized  phenol  renders  the 
dilatation  of  the  uterus,  the  use  of  the  curette,  and  the  subsequent  application  of 
fuming  nitric  acid,  less  frequently  necessary  than  has  been  the  case  hitherto. 

8.  The  injection  of  iodized  phenol  requires  to  be  carried  out  with  so  much 
care,  that  it  should  never  be  injected  except  by  means  of  a  syringe  which  will 
not  contain  more  than  one  drachm. 


1885.] 


Midwifery  and  Gynaecology. 


293 


9.  The  use  of  the  fuming  nitric  acid  should  be  limited,  as  a  rule,  to  those  cases 
in  which  dilatation  has  been  practised^  and  it  should  always  be  applied  through  a 
tube,  inserted  into  the  cervix  uteri  for  the  purpose  of  protecting  the  sides  of  that 
canal  from  the  action  of  the  acid. 

10.  The  pain  produced  by  the  application  of  any  medical  agent  to  the  intra- 
uterine cavity  does  not  bear  any  relation  to  the  activity  of  that  agent,  but  is  due 
to  one  of  two  causes — either  to  hyperesthesia,  or  to  narrowness  of  the  cervical 
canal,  especially  of  the  os  internum. — British  Med.  Journ,,  Nov,  29,  1884. 

The  Alexander- Adams'  s  Operation  for  Shortening  the  Round  Ligaments. 

Dr.  William  Gardner,  of  Glasgow,  at  the  conclusion  of  a  paper  in  which  he 
reports  six  cases,  says  :  The  class  of  cases  to  which  I  would  restrict  the  operation 
is  the  large  one  of  chronic  retroflexion  with  malposition  of  one  or  both  ovaries, 
and  if  one,  probably  the  left  (as  Lawson  Tait  has  pointed  out),  owing  to  the 
absence  of  a  valve  in  the  left  ovarian  vein.  In  simple  prolapse  the  removal  of 
triangles  from  both  anterior  and  posterior  vaginal  walls  with  restoration  of  the 
perineal  body  would,  in  most  cases,  enable  the  uterus  to  be  kept  in  position  by 
a  pessary,  and  if  this  failed  I  should  then  be  disposed  to  pull  up  the  round  liga- 
ments.   My  method  of  performing  the  operation  is  as  follows  :  — 

After  shaving  the  mons  veneris  and  groins,  I  push  the  finger  into  the  external 
abdominal  ring,  and  mark  the  invaginated  skin  with  the  nail  of  my  forefinger  on 
each  side.  This  marks  the  centre  of  my  first  incision,  which  may  be  prolonged 
either  upwards  or  downwards  if  difficulties  occur.  The  first  incision  I  make  two 
inches  long,  in  the  direction  of  Poupart's  ligament,  and  parallel  to  it,  dividing,  at 
one  stroke  of  the  knife,  skin,  superficial  fascia,  and  fat.  Generally  one  or  two  small 
vessels  require  torsion,  or  the  application  of  pressure  forceps  for  a  short  time.  I 
then  define  the  ring  thoroughly,  and  after  finding  the  fibres  of  the  round  ligament, 
I  follow  them  up  until  it  becomes  a  strong  round  cord,  upon  which  I  fix  pressure 
forceps. 

The  operation  is  then  repeated  on  the  opposite  side  till  the  same  stage  is 
reached.  An  assistant  now  passes  his  finger  into  the  vagina  and  presses  the  os 
uteri  backwards,  whilst  I  gently  but  firmly  pull  up  both  ligaments  until  the  fundus 
can  be  distinctly  felt  in  its  normal  position  through  the  parietes.  The  os  will 
then  be  found  directed  slightly  backwards.  In  most  cases  I  pull  out  each  liga- 
ment from  2^  to  4  inches,  and  then  tie  them  together,  passing  a  folded  pad  of 
gauze  under  them  to  keep  them  on  the  stretch.  I  then  pass  sutures  of  kangaroo 
tendon  through  the  skin  and  ligament,  and  also  round  the  latter,  and  bring  the 
edges  of  the  incision  closely  together.  A  drainage-tube  is  passed  under  the  liga- 
ment and  brought  out  at  the  lower  end  of  the  incision.  Listerian  dressing  is  then 
applied  in  the  usual  way,  and  the  operation  may  be  done  either  with  spray  or 
without,  according  to  the  inclination  of  the  operator.  In  either  case  the  hands 
of  the  operator  should  be  well  washed,  or  soaked  in  carbolic  lotion,  and  all  instru- 
ments should  be  kept  in  carbolic  lotion.  For  the  first  two  or  three  days  after  the 
operation  I  keep  the  patient  under  the  influence  of  opium  sufficiently  to  abolish 
acute  pain.  The  urine  may  be  drawn  off  by  catheter  every  four  hours  if  neces- 
sary. The  uterus  ought  never  to  be  lifted  with  the  sound  at  the  operation,  but 
should  in  all  cases  be  drawn  up  by  the  ligaments  alone,  on  account  of  the  danger 
(probably  remote)  of  setting  up  perimetric  inflammation.  It  must  always  be 
remembered  that,  previous  to  undertaking  the  operation,  the  uterus  must  be  ascer- 
tained to  be  freely  movable  and  capable  of  being  replaced  by  the  sound.  It  is 
not  necessary  to  insert  any  pessary  until  the  patient  is  allowed  to  get  up.  This 
may  generally  be  allowed  at  the  end  of  three  weeks,  and  a  well-fitting  watch- 

19* 


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[Jan. 


spring  pessary  is  then  the  best  support.  After  six  weeks  or  two  months  this  may 
be  dispensed  with. 

The  results  of  this  operation,  so  far,  have  been  excellent,  and  several  of  the 
patients  have  been  transformed  from  a  state  of  chronic  invalidism  to  perfect 
health.  Case  I.,  of  the  private  cases,  had  been  a  chronic  invalid  for  five  years, 
and  since  the  operation  she  has  been  able  to  walk  a  distance  of  two  or  three  miles 
at  a  time  without  inconvenience,  and  has  been  twice  pregnant.  This  case  also 
shows  that  when  there  is  prolapse  of  both  ovaries  into  Douglas's  pouch  with  con- 
sequent sterility  (owing  to  the  impossibility  of  the  fimbriated  extremity  of  the 
Fallopian  tube  applying  itself  to  the  ovary),  this  may  be  remedied  by  the  opera- 
tion, and  pregnancy  follow.  Another  advantage  gained  by  this  operation  is  that 
it  prevents  the  necessity  for  Tait's  operation  of  removal  of  the  "uterine  appen- 
dages" when  the  ovaries  are  prolapsed  with  retroversion  or  retroflexion  of  the 
uterine  body.  The  same  result  is  thereby  attained  without  the  obvious  disadvan- 
tage of  the  other  operation — viz.,  that  of  preventing  pregnancy  in  the  future. 
All  the  difficulties  of  the  operation  can  be  surmounted  by  a  course  of  operations 
on  the  dead  body,  and  any  inability  to  find  and  pull  up  the  round  ligaments  is 
probably  due  to  imperfect  performance,  as  in  my  second  hospital  case,  where  I 
was  only  able  to  find  one  ligament.  I  can  also  imagine  another  difficulty,  although 
I  have  never  had  the  misfortune  to  have  to  meet  it.  It  is  that,  owing  to  previous 
recurrent  attacks  of  pelvic  peritonitis,  the  ligaments  may  become  so  adherent  to 
their  peritoneal  investments  that  they  may  not  run  when  pulled  upon.  In  such 
cases  there  would  be  left  to  the  operator  (if  symptoms  were  sufficiently  urgent) 
the  dernier  ressort  of  removing  the  uterine  appendages  from  their  prolapsed,  and, 
probably,  adherent  position  by  Tait's  radical  operation.— The  Glasgow  Med. 
Journ.,  November,  1884. 

Ovariotomy,  with  Suture  of  the  Base  of  the  lumor  into  the  Abdominal  Wound. 

Dr.  A.  Rheinstaedter  reports,  in  the  Zeitschrift  fur  Geburtshulfe  und 
Gynalcologie,  Bd.  X.,  Heft  2,  1884,  seven  cases  of  ovariotomy,  in  which  the 
base  of  the  tumor  was  sutured  into  the  abdominal  wound,  with  good  result  in 
every  case.  After  giving  the  history  of  the  cases,  he  concludes  his  paper  with 
the  following  description  of  his  operative  procedure:  — 

The  longitudinal  incision  is  always  quite  extensive,  and  is  often  carried  above 
the  umbilicus.  The  peritoneum  is  immediately  sutured  to  the  edges  of  the 
wound.  Immediately  after  this  the  presenting  tumor  is  punctured  and  its  size 
diminished,  the  incision  being  held  open  by  the  hand  and  the  patient  placed  upon 
the  back  so  as  to  favor  the  draining  away  of  the  fluid  contents  of  the  tumor. 
The  opening  of  the  puncture  or  of  the  incision  into  the  cyst  is  then  sutured,  after 
which  the  tumor  is  gradually  drawn  out  by  means  of  dressing-forceps,  the  adhe- 
sions separated,  tied  and  cut,  until  the  greater  part  of  the  tumor  has  been  drawn 
out  of  the  abdominal  wound. 

If  the  exploring  hand  finds  that  there  is  no  pedicle,  that  the  tumor  is  inserted 
to  the  broad  ligament  by  a  large  base,  or  if  the  adhesions  to  the  abdominal  walls, 
to  the  bladder,  the  uterus,  rectum,  etc.,  are  such  that  total  extirpation  appears 
too  dangerous,  he  proceeds  to  suture  the  base  of  the  tumor  into  the  lower  part  of 
the  abdominal  wound,  after  having  closed  the  upper  part  of  the  wound  around 
the  base  of  the  tumor  as  completely  as  possible  with  silver  sutures.  The  sutures 
which  fix  the  wall  of  the  base  of  the  tumor  to  the  abdominal  wall  are  of  solid  car- 
bolized  silk,  and  are  placed  around  the  base  imrallel  to  the  edges  of  the  wound, 
at  a  distance  of  about  2  cm.  from  the  border.  During  the  application  of  the 
sutures  the  tumor  is  held  up  by  an  assistant,  whilst  another  protects  the  intes- 


1885.] 


Midwifery  and  Gynaecology. 


295 


tines,  holding  them  with  cloths  wrung  out  in  warm  chlorine  water.  The  needle 
is  first  carried  through  the  abdominal  wall  from  without  inwards,  then  carried 
through  the  wall  of  the  tumor,  then  back  from  within  outwards.  With  each 
suture  the  operator  takes  in  about  4  cm.  of  the  wall  of  the  tumor.  The  sutures 
are  applied  as  rapidly  as  possible. 

When  the  tumor  is  completely  sutured  in  it  is  found  that  the  abdominal  wound 
is  closed,  and  that  the  peritoneal  surfaces  are  in  contact.  The  sutures  which  were 
put  in  at  an  early  stage  of  the  operation  to  fix  the  peritoneum,  may  now  be 
removed.  The  tumor  is  now  cut  off  close  to  the  abdominal  wall ;  a  very  simple 
operation  when  the  cyst  is  unilocular.  If  it  is  multilocular  and  the  vessels  of 
large  size,  a  double  ligature  may  be  passed  through  the  base  and  tied  on  each 
side  before  the  tumor  is  cut  off,  in  order  to  prevent  hemorrhage. 

The  cleansing  of  the  sac  is  to  be  done  with  the  hand  for  the  most  part,  so  as  to 
remove  the  solid  matters  of  the  tumor.  Sometimes,  when  they  are  very  adhe- 
rent to  the  sac  wall,  or  when  there  is  considerable  hemorrhage,  they  may  be 
ligated  ;  the  two  sides  may  be  tied  and  then  excision  performed.  When  the 
ovarian  elements  are  removed,  the  edge  of  the  wound  in  the  sac  may  be  sutured 
again  to  the  cutaneous  surface  by  a  perpendicular  suture  of  carbolized  silk.  A 
drainage-tube  is  then  put  in  place.  At  the  present  time  the  author  establishes 
drainage  without  passing  a  drainage-tube  to  the  bottom  of  the  sac,  through  Doug- 
las's sac  and  the  vagina,  being  convinced  that  lateral  decubitus  is  sufficient  to 
cause  the  secretions  to  drain  away.  After  drainage  is  established,  the  sac  is 
tamponed  with  iodoform  gauze.  The  remainder  of  the  compress  bandage  is 
composed  of  salicylated  tow  or  wadding,  and  of  bands  of  gauze  steeped  in  carbol- 
ized water. 

As  regards  the  after-treatment,  the  sutures  uniting  the  walls  of  the  sac  to  the 
edges  of  the  abdominal  wound  are  removed  as  soon  as  a  gangrenous  point  appears 
on  the  skin;  sometimes  this  is  necessary  on  the  day  after  the  operation.  The 
union  of  the  peritoneal  surfaces  is  solid  within  about  twenty-four  hours.  The 
tampons  are  removed  on  the  first  day,  and  replaced  by  fresh  iodoform  gauze. 
The  dressing  is  renewed  every  day,  and  the  drain  washed  with  weak  chlorine 
water.  During  the  first  few  days  after  the  operation  the  inner  wall  of  the  sac  is 
of  a  grayish-yellow  color.  This  layer  falls  off  by  suppuration,  and  is  replaced 
by  red  granulations  which  tend  to  unite.  If  suppuration  is  tardy,  a  mixture  of 
wine  of  camphor  and  tincture  of  myrrh  maybe  used,  tampons  of  wadding  soaked 
in  it  and  applied  to  the  grayish-yellow  surface.  Union  of  the  cyst- walls  is  fur- 
ther favored  by  bringing  together  the  edges  of  the  abdominal  wound  by  means  of 
straps  of  adhesive  plaster.  Within  about  five  days,  as  a  rule,  all  the  sutures  are 
removed,  and  the  size  and  extent  of  the  drain  are  progressively  diminished  as 
union  takes  place. — Archives  de  Tocologie,  November,  1884. 

Gonorrheal  Disease  of  the  Uterine  Appendages  and  the  Operative  Treatment. 
Sanger,  of  Leipzig,  read  a  paper  on  this  subject  before  the  Society  of  German 
Naturalists  and  Physicians,  in  Magdeburg.  His  opinion  is  that  gonorrhoea  in  the 
female,  and  the  affections  of  the  uterine  appendages  connected  with  it  have  not 
yet  received  the  attention  due  them.  Gonorrhoea  furnishes  a  far  higher  percent- 
age of  severe  chronic  affections  of  the  pelvic  organs  than  puerperal  fever,  and  a 
far  higher  percentage  of  severe  incurable  cases  than  syphilis.  The  frequency  of 
gonorrhoea!  affections  is  so  great  that  about  one-ninth  of  all  gynaecological  cases, 
or  even  more,  is  primarily  caused  by  it,  As  regards  the  severity  of  the  forms,  it 
depends  very  much  upon  the  coincident  affections  of  the  tubes  and  ovaries,  and 
of  the  pelvic  peritoneum.    The  principal  centre  is  to  be  found  in  the  tubes  ;  with 


296 


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[Jan. 


the  exceptions  of  simple  catarrh,  and  of  hydro-  and  haemato-salpinx,  the  severe 
forms  of  tubal  disease  are  only  of  an  infectious  nature ;  and  in  this  may  be  reck- 
oned septic  salpingitis,  which  may  be  either  puerperal  or  non-puerperal ;  in  each 
case  it  extends  from  the  vagina,  cervix,  or  uterus.  There  are,  furthermore,  a 
tuberculous,  a  syphilitic  (Bouchard,  Lepine),  and  an  actinomycotic  (Zemann) 
salpingitis  ;  but  the  gonorrheal  is  unquestionably  the  most  frequent  form.  There 
is  also  a  mixed  form,  a  puerpero-gonorrhceal  salpingitis.  After  parturition  or  an 
abortion,  the  results  of  a  recent  or  an  old  gonorrhoea  are  seen  in  a  sudden  attack 
of  salpingitis. 

As  has  already  been  stated,  gonorrheal  salpingitis,  giving  rise  to  an  acute  or 
chronic  inflammation,  or  to  pyosalpinx,  is  a  chief  cause  of  severe  disease  of  the 
uterine  appendages  and  the  pelvic  peritoneum.  Sanger  cannot  accept  Noegge- 
rath's  division  of  perimetritis  into  an  acute,  relapsing,  or  chronic  form  ;  he  classi- 
fies gonorrheal  affections  as  urethral,  vesical,  and  renal:  those  of  the  vulva  and 
vulval  glands ;  vaginal,  and  uterine  (gonorrheal  catarrh)  ;  and  of  the  uterine 
appendages,  which  he  again  classifies  as  gonorrheal  disease  of  the  tubes  (salpin- 
gitis, pyosalpinx,  peri-salpingitis ;  of  the  ovaries  (perioophoritis,  oophoritis  and 
abscess  of  the  ovary)  ;  of  the  broad  ligaments  (inflammation  of  the  cellular  tissue, 
parametritis  and  abscess  formations).  These  forms  of  disease  may  be  either  uni- 
lateral or  bilateral,  and  there  may  also  be  a  coexisting  perimetritis  ;  they  may 
result  in  pelvic  peritonitis,  or  in  diffuse  perimetritis.  They  may  be  either  acute 
or  chronic. 

As  regards  the  diagnosis  of  gonorrheal  diseases  in  women,  it  seems  that  since 
the  discovery  of  the  gonococcus  of  Neisser,  this  should  determine  the  diagnosis 
in  doubtful  cases  ;  although  the  latest  researches  of  Bumm  seem  to  render  this 
somewhat  uncertain.  It  seems,  however,  that  there  can  scarcely  be  a  doubt  as 
to  the  microbic  nature  of  gonorrhea.  As  far  as  concerns  the  infectiousness 
of  latent  gonorrhea,  Sanger  thinks  it  not  improbable  that  this  is  determined  by 
the  presence  of  spores  of  permanent  form,  a  special  form  of  the  gonococcus  ;  more 
especially  since  permanent  forms  of  other  bacilli,  as  of  splenic  fever,  are  known. 
In  order  to  limit  the  frequency  of  gonorrheal  infection  in  women,  Sanger  recom- 
mends a  general  prophylaxis ;  the  dangers  of  gonorrhea,  he  thinks,  should  be 
plainly  stated  to  the  public ;  and  a  married  person  should  be  especially  warned 
against  intercourse  until  all  traces  of  the  disease  are  thoroughly  eradicated.  He 
mentions  a  casein  which  a  man  had  had  gonorrhea  ten  years  before,  and  still  had 
prostatitis  ;  the  wife  took  gonorrhea  and  became  sterile.  Special  prophylaxis 
should  consist  in  the  strictest  treatment  of  infected  women ;  and  he  thinks  it  ad- 
visable to  inject  Crede's  nitrate  of  silver  solution  into  the  fossa  navicularis  of  the 
man  after  impure  intercourse,  as  is  done  in  the  Leipzig  clinic. 

For  the  treatment  of  gonorrhea,  Sanger  recommends  the  daily  use  of  injec- 
tions of  corrosive  sublimate  solution,  one  per  cent.  After  this  has  been  used  for 
some  time,  nitrate  of  silver  solution  may  be  used,  with  tincture  of  iodine  or  dilute 
nitric  acid.  These  should  also  be  injected  into  the  cavity  of  the  uterus.  As 
regards  the  treatment  of  diseases  of  the  uterine  appendages  dependent  upon  gonor- 
rhea, Sanger  advises  extirpation  of  the  appendages  ;  it  is  especially  important, 
for  the  after-results  of  salpingotomy,  that  the  tubes  be  thoroughly  removed.  This 
operation  has  been  quite  frequently  performed  recently  for  pyosalpinx  ;  and  cas- 
tration with  removal  of  larger  or  smaller  portions  of  the  tubes  still  more  frequently 
for  oophoritis  and  perioophoritis.  In  such  cases  a  combined  operation,  a  salpingo- 
cbphorectomy,  is  often  necessary.  Sanger  mentioned  four  cases  in  which  the 
combined  operation  had  been  performed.  In  one  case  the  results  were  perfect, 
and  the  patient  was  entirely  freed  from  pain  ;  the  second  and  third  cases  resulted 
well ;  the  fourth  was  but  little  benefited. 


1885.] 


Medical  Jurisprudence  and  Toxicology. 


297 


Frankel,  of  Breslau,  said  that  he  had  made  quite  a  number  of  examinations  in 
the  Freiburg  Clinic  with  reference  to'  the  gonococci.  Naturally  the  case  is  simple 
enough,  if  they  are  found  in  large  numbers.  But  when  only  a  few  or  single 
cocci  are  found,  as  is  often  the  case  in  chronic  latent  gonorrhoea,  or  when,  after 
repeated  examination  of  the  genital  passages  and  of  the  secretion,  at  different 
times,  no  cocci  are  found  at  all,  there  must  necessarily  be  considerable  doubt. 
Certainly  in  old,  chronic  forms,  in  which  the  clinical  symptoms  have  disappeared, 
the  confirmation  of  the  diagnosis  by  means  of  the  microscope  is  desirable  ;  and  it 
is  just  here  that  we  may  fail  to  find  gonococci.  There  are  some  cases,  especi- 
ally in  children,  in  which  the  cocci  are  not  so  very  scarce  in  the  secretion  of  the 
vulva  and  vagina,  and  yet  give  rise  to  no  infection  on  the  most  complete  experi- 
ments. It  seems,  therefore,  that  the  clinical  symptoms,  as  most  clearly  presented 
in  the  vulva,  the  vulval  glands  and  their  ducts,  and  on  the  part  of  the  uterus  and 
its  appendages,  are  always  the  most  certain  and  clear.  Nevertheless,  the  central 
microscopical  examinations  of  the  secretion  in  every  case  are  not  only  desirable, 
but  necessary.  From  the  results  of  Bumm's  careful  researches,  and  his  differen- 
tiation of  various  kinds  of  gonococci  it  seems  that  there  are,  perhaps,  in  the  geni- 
tal secretions  of  the  female,  cocci  of  different  value  or  dignity  ;  and  which  of 
these  are  active  and  capable  of  infecting  can  only  be  determined  by  inoculation 
experiments  on  the  genital  mucous  membrane  of  men  or  monkeys.  He  asked 
Sanger  whether,  since  he  designated  infection  as  the  cause,  without  exception, 
of  inflammation  of  the  tubal  mucous  membrane,  he  would  deny  the  catarrhal 
salpingitis  with  its  consecutive  hydrosalpinx.  This  is  with  difficulty  diagnosti- 
cated, by  examination,  from  purulent  salpingitis,  but  after  longer  observation  of 
the  clinical  course  of  the  case  it  is  seen  that  the  accompanying  inflammatory 
phenomena,  perisalpingitis,  oophoritis,  perioophoritis  and  perimetritis,  are  usually 
absent  in  the  simple  catarrhal  form. — Centra  lb.  fiir  Gynakol.,  October  11,  1884- 


MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY. 

The  External  Pistol-Shot  Wounds. 
Dr.  D.  B.  N.  Fish,  of  Amherst,  at  the  close  of  a  paper  on  this  subject,  read 
before  the  Massachusetts  Medico-Legal  Society,  gives  the  following  summary : 
The  distance  at  which  a  pistol-shot  has  been  fired  may  be  estimated  by  the  fol- 
lowing general  rules :  — 

(1)  From  a  great  distance  the  entrance  wound  will  usually  be  large  and  irregu- 
lar ;  there  will  be  absence  of  any  great  degree  of  lividity  of  its  edges,  and  absence 
of  the  marks  of  powder.  The  wound  of  exit,  if  one  is  present,  will  usually  be 
larger  than  the  wound  of  entrance.  At  any  distance  the  edges  of  wounds  of 
entrance  will  usually  be  inverted,  those  of  exit  everted. 

(2)  From  a  short  distance  the  entrance  and  exit  wounds  will  generally  be 
nearly  equal  in  size  :  the  edges  of  the  former  will  be  blackened,  and  powder 
grains  will  be  imbedded  in  the  skin,  but  there  will  be  absence  of  scorchings  and 
brandings  of  powder. 

(3)  Close  to  the  body  the  entrance  wound  will  generally  be  larger  than  the 
exit.  There  will  often  be,  in  addition  to  the  tattooing  of  the  skin  by  unburned 
grains  of  powder,  a  mark  or  brand  made  by  the  flame  of  the  gases  and  of  the 
burning  powder,  by  the  soot  of  the  partly  burned  powder,  and  by  the  residue  or 
ash  of  the  wholly  burned  powder.    As  a  rule  this  brand,  which  may  consist  of  a 


298 


Progress  of  the  Medical  Sciences. 


[Jan. 


burning  alone  of  the  hair,  the  skin,  or  the  clothing,  or  of  a  burning  and  blacken- 
ing of  the  skin  or  clothing,  will  appear  at  one  side  of  the  bullet  hole. 

The  direction  of  the  shot  will  be  shown  in  part  by  the  trajectory  of  the  ball — 
a  subject  of  which  this  paper  does  not  treat — and  by  the  location  of  the  wound  of 
entrance.  The  character  of  the  opening,  whether  rounded  or  oval,  may  give 
some  indication  of  the  angle  at  which  the  weapon  has  been  held. 

The  position  of  the  weapon  (and  whenever  this  term  is  used  I  wish  to  be  un- 
derstood to  mean  not  its  angle  to  or  distance  from  the  body,  but  the  manner  or 
position  in  which  it  is  held  ;  that  is,  whether  it  is  held  with  its  hammer  and  sight 
above  the  barrel,  as  in  the  usual  position  for  firing,  or  with  the  hammer  and  sight 
below  the  barrel,  as  when  the  weapon  is  turned  upside  down,  or  in  any  other 
position  of  the  hammer  and  sight  relative  to  the  barrel  of  the  weapon)  the  posi- 
tion of  the  weapon  is  to  be  determined  by  the  following  rule  :  When  the  brand 
appears  upon  the  hair,  the  skin,  or  clothing,  at  one  side  of  the  bullet  hole,  hold 
the  weapon  with  its  muzzle  to  the  bullet  hole  so  that  the  line  of  its  hammer  and 
sight  will  meet  a  line  drawn  from  the  centre  of  the  bullet  hole  through  the  centre 
of  the  brand,  and  it  will  show  the  exact  position  of  the  weapon  when  fired. 

This  rule  is  deduced  from  the  newly-discovered  fact  that,  owing  to  the  recoil 
of  the  muzzle  of  the  weapon  in  the  direction  of  its  sight,  this  brand,  when  it  ap- 
pears at  one  side  of  the  bullet  hole,  will  appear  upon  that  side  which  corresponds 
to  the  side  of  the  hammer  and  sight  in  their  position  relative  to  the  bore  or  barrel 
of  the  weapon.  That  is,  if  the  weapon  is  held  upside  down  the  brand  will  appear 
below  the  bullet  hole. 

Accidental  wounds  are  generally  near  wounds.  When  inflicted  from  a  distance 
they  cannot  be  distinguished  from  homicidal  wounds.  In  shots  fired  near  by, 
when  a  person  is  known  to  have  been  shot  while  standing,  an  unnatural  position 
of  the  weapon,  as  shown  by  the  location  of  the  brand,  will  tend  to  corroborate  a 
claim  of  accidental  shooting.  So,  if  one  is  known  to  have  shot  himself,  an  un- 
natural position  of  the  weapon  will  show  that  the  shot  was  probably  accidental. 
The  location  of  the  wound  and  the  course  taken  by  the  ball  may  also  characterize 
the  wound  as  accidental. 

Homicidal  wounds  inflicted  within  the  suicide  limit  have  heretofore  been  dis- 
tinguished' from  suicidal  wounds  alone  by  the  location  of  the  wound  and  by  the 
uncertain  evidence  presented  by  the  trajectory  of  the  ball.  When  the  location 
of  the  wound  has  been  such  that  a  person  might  easily  have  inflicted  it  upon 
himself,  there  have  been  no  means  of  determining  from  its  character  whether  it 
was  homicidal  or  suicidal.  To  aid  in  distinguishing  between  such  wounds,  I  offer 
the  following  rule  :  When  the  location  of  the  b  rand,  relative  *to  the  bullet  hole, 
shows  that  the  weapon  has  been  held  in  a  position  of  its  hammer  and  sight  im- 
possible or  improbable  for  a  suicide,  it  is  probable  that  a  murder  has  been  com- 
mitted. Certain  relative  locations  of  this  brand  may  also  indicate  that  the  victim 
has  been  shot  while  in  a  reclining  position. 

Multiple  wounds  are  usually  homicidal,  but  may  be  either  accidental  or  sui- 
cidal. 

Shots  fired  beyond  the  usual  suicide  limit  are  probably  homicidal. 

Suicidal  wounds.  It  is  said  that  the  suicide  rarely  holds  the  muzzle  of  his 
pistol  at  more  than  eight  inches  from  the  body.  Suicides  generally  fire  at  the 
side  or  front  of  the  head,  next  at  the  heart ;  they  sometimes  fire  at  the  back  of 
the  head. 

The  distance  from  the  body  at  which  the  weapon  must  be  held  to  show  the 
brand  plainly,  is,  probably,  very  nearly  as  follows  :  for  small  pistols  and  revolvers, 
not  over  four  to  six  inches ;  for  large  weapons  of  this  class  not  over  twelve  to 
fourteen  inches. — Boston  Med,  and  Surg.  Journ.,  Oct.  2,  1884. 


American  Journal  of  the  Medical  Sciences. 


299 


Bellevue  Hospital  Medical  College. 


CITY  OF  NEW  YORK. 


SESSIONS   OF  1884-85. 

The  standard  of  Medical  Ethics  recognized  by  the  College  is  embodied  in  the  Code 
of  Ethics  of  the  American  Medical  Association. 

The  Collegiate  Year  embraces  the  Regular  Winter  Session  and  a  Spring  Session. 

The  Regular  Session  begins  on  Wednesday,  September  17,  1881,  and  ends  about 
the  middle  of  March,  1885.  During  this  Session,  in  addition  to  the  regular  didactic 
lectures,  two  or  three  hours  are  daily  allotted  to  clinical  instruction.  Attendance 
upon  two  regular  courses  of  lectures  is  required  for  graduation. 

The  Spring  Session  consists  chiefly  of  recitations  from  Text-Books.  This  Session 
begins  about  the  middle  of  March,  and  continues  until  the  middle  of  June.  During 
this  Session,  daily  recitations  in  all  the  departments  are  held  by  a  corps  of  Examiners 
appointed  by  the  Faculty.  Short  courses  of  lectures  are  given  on  special  subjects, 
and  regular  clinics  are  held  in  the  Hospital  and  in  the  College  building. 

FACULTY. 

ISAAC  E.  TAYLOR,  M.D., 
Emeritus  Prof,  of  Obstetrics  and  Diseases  of  Women  and  Children,  and  President  of  the  Faculty. 

FORDYCE  BARKER,  M.D.,  LL.D.,  i  BENJAMIN  W.  McCREADT,  M.D., 

Professor  of  Clinical  Midwifery  and  Diseases        Emeritus  Professor  of  Materia  Medica  and 
of  Women.  Therapeutics. 


AUSTIN"  FLINT,  M.D.,  LL.D., 
Prof,  of  the  Principles  and  Practice  of  Medicine, 
and  Clinical  Medicine. 

FREDERICK  S.  DENNIS,  M.D., 
Professor  of  Principles  and  Practice  of  Surgery 
and  Clinical  Surgery. 

LEWIS  A.  SAYRE,  M.D., 
Professor  of  Orthopedic  Surgery  aud  Clinical 
Surgery. 
ALEXANDER  B.  MOTT,  M.D., 
Professor  of  Clinical  and  Operative  Surgery. 

WILLIAM  T.  LUSK,  M.D.. 
Professor  of  Obstetrics  and  Diseases  of  Women 


A.  A.  SMITH,  M.D., 
Professor  of  Materia  Medica  and  Therapeutics 
and  Clinical  Medicine. 
AUSTIN  FLINT,  Jr.,  M.D., 
Professor  of  Physiology  and  Physiological 
Anatomy,  and  Secretary  of  the  Faculty. 
JOSEPH  D.  BRYANT,  M.D., 
Professor  of  Anatomy  and  Cliuical  Surgery,  and 
Associate  Professor  of  Orthopedic  "Surgery. 
R.  00 DEN  DOREMUS,  M.D.,  LL.D., 
Professor  of  Chemistry  and  Toxicology. 
EDWARD  G.  JANEWAY,  M.D., 
Professor  of  Pathological  Anatomy  and  Clinical 
Medicine,  and  Associate  Professor  of  Prin- 
ciples and  Practice  of  Medicine. 


and  Children  and  Clinical  Midwifery 

PROFESSORS  OF  SPECIAL  DEPARTMENTS,  Etc. 


BEVERLY  ROBINSON,  M.D., 
Cliuical  Professor  of  Medicine. 
FRANCKE  H.  BOSWORTH,  M.D., 
Professor  of  Diseases  of  the  Throat. 
CHARLES  A.  DOREMUS,  M.D.,  Ph.D., 
Professor  Adjunct  to  the  Chair  of  Chemistry  and 
Toxicology. 
LEROY  M.  YALE,  M.D.. 
Lecturer  Adjunct  on  Diseases  of  Children. 
GASPAR  GRISWOLD,  M.D.,  M.R.C.S., 
Demonstrator  of  Anatomy. 


HENRY  D.  NOYES,  M.D., 
Professor  of  Ophthalmology  and  Otology. 

EDWARD  L.  KEYES,  M.D., 
Prof,  of  Cutaneous  and  Genito-Urinary  Diseases. 

JOHN  P.  GRAY,  M.D.,  LL.D  , 
Professor  of  Psychological  Medicine  and  Medical 
Jurisprudence. 

J.  LEWIS  SMITH,  M.D., 
Clinical  Professor  of  Diseases  of  Children. 

FEES  FOR  THE  REGULAR  SESSION. 

Fees  for  Tickets  to  all  the  Lectures,  Clinical  and  Didactic  .       .      .  . 

Fees  for  Students  who  have  attended  two  full  courses  at  other  Medical  Colleges,  and  ) 

for  Graduates  of  other  Medical  Colleges   .       .      .  $ 

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No  Fees  for  Lectures  are  required  of  third-course  Students  who  have  attended  their 

second  course  at  the  Bellevue  Hospital  Medical  College. 

FEES  FOR  THE  SPRING  SESSION. 

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For  the  Annual  Circular  and  Catalogue,  giving  regulations  for  graduation  and  other  informa- 
tion, address  Prof.  Austin  Flint,  Jr.,  Secretary,  Bellevue  Hospital  Medical  College. 


Lea  Brothers  &  Co.'s  Medical  and  Surgical  Works. 


FLINT'S  PRACTICE.— Fifth  Edition,  with  Appendix. 
A  Treatise  on  the  Principles  and  Practice  of  Medicine.   Designed  for 

the  use  of  Students  and  Practitioners  of  Medicine.  With  an  Appendix  on  the  Researches  of 
Koch,  and  their  bearing  on  the  Etiology,  Pathology,  Diagnosis  and  Treatment  of  Phthisis. 
By  Austin  Flint,  M.D  ,  Professor  of  the  Principles  and  Practice  of  Med.  and  of  Clin.  Med. 
in  Bellevue  Hospital  Medical  College,  N.  Y.  Fifth  edition,  revised  and  largely  rewritten.  In 
one  large  and  closely-printed  octavo  volume  of  1160  pages.  Cloth,  $5.50  ;  leather,  $6.50  ;  half 
Russia,  $7. 


This  admirable  work  no  longer  needs  the  commen- 
dation of  the  press,  and  the  fifth  edition  will  in- 
crease its  popularity.  The  author  has  aimed  to 
bring  it,  in  all  respects,  up  to  the  level  of  the 
present  state  of  advancement  in  both  the  principles 
and  practice  of  medicine,  and  it  is  safe  to  say  that 
he  has  succeeded  in  his  usual  thorough  manner. 
The  reader  will  meet  in  it  all  the  latest  words  on 
the  subjects  which  it  treats.  The  present  edition  is 
essentially  a  nesv  work,  constituting,  not  only  for 
the  student,  the  best  text-book  extant,  but  the  prac- 
titioner can  find  no  other  volume  in  which  the 
scieuce  and  art  of  medicine  are  presented  with  so 
much  clearness  and  in  so  condensed  a  style. — 
American  Practitioner,  May,  1881. 

A  well-known  writer  and  lecturer  on  medicine 


recently  expressed  an  opinion  in  the  highest  degree 
complimentary  to  the  admirable  treatise  of  Dr.  Flint, 
and  in  eulogizing  it  he  described  it  accurately  as 
"  readable  and  reliable."  No  text-book  is  more  cal- 
culated to  enchain  the  interest  of  the  student,  and 
none  better  classifies  the  multitudinous  subjects  in- 
cluded in  it.  It  has,  already,  so  far  won  its  way  in 
Eagland,  that  no  inconsiderable  number  of  men  use 
it  alone  in  the  study  of  pure  medicine;  and  we  caa 
say  of  it  that  it  is  in  every  way  adapted  to  serve 
not  only  as  a  complete  guide,  but  also  as  au  ample 
instructor  in  the  science  and  practice  of  medicine. 
The  style  of  Dr.  Flint  is  always  polished  and  en- 
gaging. The  work  abounds  in  perspicuous  expla- 
nation, and  is  a  most  valuable  text-book  of  med- 
icine.— London  Medical  News. 


SMITH  ON  CHILDREN. -Fifth  Edition. 
A  Complete  Practical  Treatise  on  the  Diseases  of  Children.  By  J.  Lswrs 

Smith,  M.D.,  Clinical  Professor  of  Diseases  of  Children  in  the  Bellevue  Hospital  Medical  Col- 
lege, New  York.  Fifth  edition,  thoroughly  revised  and  rewritten.  In  one  handsome  octavo 
volume  of  836  pages,  with  illustrations.  Cloth,  $4.50;  leather,  $5.50;  very  handsome  half 
Russia,  raised  bands,  $6. 


That  a  book  professing  to  treat  of  diseases  of  chil- 
dren should  have  reached  a  fifth  edition  is  in  itself 
fair  evidence  of  its  worth,  the  more  especially  as  it 
has  not  the  field  to  itself,  but  has  to  compete  with 
several  other  excellent  manuals.  The  chapter  on 
Rachitis  is  excellent,  and  well  up  to  the  day — a 
remark  which  may  with  equal  justice  be  applied  to 
the  chapter  on  Scrofula,  which  is  one  of  the  best  we 


remember  to  have  read.  The  diseases  of  the  nervous 
system  are  well  described,  and  so,  for  the  most  part, 
are  those  of  the  lungs.  Dr.  Smith  w  mid  appear  to 
be  quite  au  entrant  with  the  work  done  on  this 
side  of  the  world,  and  refers  freely  to  English  and 
foreign  authors,  as  well  as  to  periodicals  especially 
devoted  to  children's  diseases. — British  Medical 
Journal,  May  6,  1882. 


TUKE  ON  THE  INFLUENCE  OF  THE  MIND  UPON  THE  BODY 
IN  HEALTH  AND  DISEASE.— New  Edition. 
Illustrations  of  the  Influence  of  the  Mind  upon  the  Body  in  Health 

and  Disease.  Designed  to  elucidate  the  Action  of  the  Imagination.  By  Daniel  Hack 
Tuke,  M.D.,  Joint  Author  of  the  Manual  of  Psychological  Medicine,  etc.  New  edition, 
thoroughly  revised  and  rewritten.  In  one  8vo.  volume  of  467  pages,  with  two  colored  plates. 
Cloth,  $3. 

tation.  Guided  by  an  enlightened  deduction,  the 
author  has  reclaimed  for  science  a  most  interesting 
domain  in  psychology,  previously  abandoned  to 
charlatans  and  empirics.  This  book,  well  conceived 
and  well  written,  must  commend  itself  to  every 
thoughtful  understanding.  —  New  Yorli  Medical 
Journal,  Sept.  6,  1884. 


It  is  impossible  to  peruse  these  interesting  chap- 
ters without  being  convinced  of  the  author's  perfect 
sincerity,  impartiality,  and  thorough  mental  grasp. 
Dr.  Tuke  has  exhibited  the  requisite  amount  of  sci- 
entific address  on  all  occasions,  and  the  more  intri- 
cate the  phenomena  the  more  firmly  has  he  adhered 
to  a  physiological  and  rational  method  of  interpre- 


BABTHOLOW  ON  ELECTRICITY.— Second  Edition. 
A  Practical  Treatise  on  Electricity  in  its  Applications  to  Medicine.  By 

Roberts  Bartholow,  A.M.,  M.D.,  LL.D.,  Professor  of  Materia  Medica  and  General  Thera- 
peutics in  the  Jefferson  Medical  College  of  Philadelphia.  Second  edition,  thoroughly  revised. 
In  one  very  handsome  octavo  volume  of  292  pages,  with  109  illustrations.    Cloth,  $2.50. 


A  most  excellent  work,  addressed  by  a  practi- 
tioner to  his  fellow  practitioners,  ,  and  therefore 
thoroughly  practical.  The  work  now  before  us  has 
the  exceptional  merit  of  clearly  pointing  out  where 
the  benefits  to  be  derived  from  electricity  must 
come.  It  contains  all  and  everything  that  the  prac- 
titioner needs  in  order  to  understand  intelligently 
the  nature  and  laws  of  the  agent  he  is  making  use 
of,  and  for  its  proper  application  in  practice.  In  a 
condensed  practical  form,  it  presents  to  the  phy- 
sician all  that  he  would  wish  to  remember  after 
perusing  a  whole  library  on  medical  electricity, 
including  the  results  of  the  latest  investigations. 
It  is  the  book  for  the  practitioner,  and  the  necessity 
for  a  second  edition  proves  that  it  hasbein  appreci- 


ated by  the  profession.— Phys,  and  Surg.  Dec.  1882. 

Dr.  Bartholow  has  not  failed  to  introduce  in  their 
appropriate  places  most  of  the  new  facts  and  appli- 
cations of  electricity  to  medicine  that  have  been 
brought  forward  in  recent  years.  In  short,  the 
book  is  fully  up  to  the  times.  We  welcome,  as  an 
important  feature,  the  full  treatment  given  to  the 
subject  of  electro-diagnosis.  We  may  safely  say 
that  there  is  to-day  no  book  on  the  subject  in  the 
English  language  move  trustworthy  than  this  one. 
It  contains  all  that  the  general  practitioner  or,  in- 
deed, the  expert  will  ever  put  into  practice  — The 
Journal  of  Nervous  and  Mental  Disease,  Jan. 
1S83. 


LEA  BROTHERS  &  CO.,  Philadelphia. 


THE 

AMERICAN  JOURNAL 
OF  THE  MEDICAL  SCIENCES 

FOR    APRIL,   188  5. 


CONTRIBUTORS  TO  THIS  VOLUME. 


A.  C.  ABBOTT,  M.D.,  of  Baltimore,  Maryland. 

SAMUEL  ASHHURST,  M.D.,  Surgeon  to  the  Children's  Hospital,  Philadelphia. 

G.  H.  BALLERAY,  M.D.,  Surgeon  to  St.  Joseph's  Hospital,  Paterson,  New  Jersey. 

J.  B.  CHAPIN,  M.D.,  Physician-in- Chief  of  the  Pennsylvania  Hospital  for  the  Insane, 

Philadelphia. 
W.  J.  CONKLIN,  M.D.,  of  Dayton,  Ohio. 

P.  S.  CONNER,  M.D.,  Prof,  of  Anatomy  and  Clin.  Surgery  in  Medical  College  of  0?do. 
WILLIAM  T.  COUNCILMAN,  M.D. Associate  in  Pathology,  Johns  Hopkins  University. 
EDWARD  COWLES,  M.D.,  Superintendent  of  the  McLean  Asylum  for  the  Insane, 

Somerville,  3Iass. 
JOHN  L.  DICKEY,  M.D.,  of  Wheeling,  W.  Va. 

LOUIS  A.  DUHRING,  M.D.,  Prof,  of  Diseases  of  the  Skin  in  the  Univ.  ofPenna. 
CHARLES  W.  DULLES,  M.D.,  Surgical  Registrar  of  the  Hospital  of  the  University  of 
Pennsylvania. 

THOMAS  DWIGHT,  M.D.,  Parkman  Professor  of  Anatomy,  Harvard  University. 
GUSTAVUS  ELIOT,  M.D.,  of  New  Haven,  Connecticut. 

H.  D.  FRY,  M.D.,  of  Washington,  D.  C. 

J.  W.  GLEITSMANN,  M.D.,  Surgeon  to  the  German  Dispensary,  New  York. 

ALLAN  McLANE  HAMILTON,  M.D. ,  one  of  the  Consulting  Physicians  to  the  New 

York  City  Insane  Asylum. 
GEORGE  C.  HARLAN,  M.D.,  Surgeon  to  theWills  [ Ophthalmic']  Hospital,  Philadelphia. 
ROBERT  P.  HARRIS,  M,D.,  of  Philadelphia. 
GUY  HINSDALE,  M.D.,  of  Philadelphia. 

HENRY  HUN,  M.D.,  Lecturer  on  Nervous  Diseases  in  the  Albany  Medical  College. 
EDWARD  JACKSON,  M.D.,  Clinical  Assistarit  in  the  Eye  Department  of  the  Philadel- 
phia Polyclinic. 

ABRAHAM  JACOBI,  M.D.,  Professor  of  the  Diseases  of  Children  in  the  College  of 

Physicians  and  Sttrgeons,  New  York. 
G.  W.  H.  KEMPER,  M.D.,  of  Muncie,  Indiana. 
PHILIP  COOMBS  KNAPP,  M.D.  {Harvard) ,  of  Boston. 

A.  H.  P.  LEUF,  M.D.,  Pathologist  to  St.  Mary's  General  Hospital,  Brooklyn,  N.  Y. 

SARAH  J.  McNUTT,  M.D.,  Lecturer  on  Children's  Diseases  in  the  New  York  Post- 
Graduate  Medical  College. 

CHARLES  B.  NANCREDE,  M.D.,  Surgeon  to  the  Ejnscopal  Hospital,  Philadelphia. 

CHARLES  A.  OLIVER,  M.D.,  Ophthalmic  and  Aural  Surgeon  to  St.  Mary's  Hospital, 
Philadelphia. 

WILLIAN  OSLER,  M.D.,  Professor  of  Clinical  Medicine  in  the  University  of  Penna. 
GEORGE  A.  PIERSOL,  M.D.,  Demonstrator  of  Normal  Histology  in  the  Univ.  of  Penna. 
J.  C.  REEVE,  M.D.,  of  Dayton,  Ohio. 

JOHN  J.  REESE,  M.D.,  Prof,  of  Medical  Jurisprudence  and  Toxicology  in  the  Univer- 
sity of  Pennsylvania. 

EDWARD  J.  REICHERT,  M.D.,  Demonstrator  of  Experimental  Physiology  and  Experi- 
mental Therapeutics  in  the  University  of  Pennsylvania. 

JOS.  G.  RICHARDSON,  M.D.,  Prof,  of  Hygiene  in  the  University  of  Pennsylvania. 

ROBERT  P.  ROBINS,  M.D.,  Assistant  Demonstrator  of  Clin.  Med.  in  Univ.  of  Penna. 

W.  S.  W.  RUSCHENBERGER,  M.D.,  Medical  Director,  U.  S.  N 

ROBERT  SATTLER,  M.D.,  Ophthalmic  Surgeon  to  Cincinnati  Hospital. 

FRANCIS  J.  SHEPHERD,  M.D.,  CM.,  Prof,  of  Anat.  in  McGill  University,  Montreal. 

J.  LEWIS  SMITH,  M.D.,  Clinical  Professor  of  Diseases  of  Children  in  Bellevue  Hos- 
pital  Medical  College,  New  York. 

J.  M.  SPEAR,  M.D.,  of  Cumberland,  Maryland. 

GEORGE  M.  STERNBERG,  M.D.,  Major  and  Surgeon,  U.  S.  A. 

JAMES  TYSON,  M.D.,  Professor  of  Pathology  in  the  University  of  Pennsylvania. 

JOHN  VAN  BIBBER,  M.D.,  of  Baltimore. 

J.  COLLINS  WARREN,  M.D.,  Assistant  Professor  of  Surgery  in  Harvard  University. 
EDMUND  C.  WENDT,  M.D.,  of  New  York. 

HENRY  R.  WHARTON,  M.D.,  Surgeon  to  the  Children's  Hospital,  Philadelphia. 
JAMES  C.  WHITE,  M.D.,  Professor  of  Dermatology  in  Harvard  University. 
JAMES  C.  WILSON,  M.D.,  Physician  to  the  Philadelphia  Hospital. 
RANDOLPH  WINSLOW,  M.D.,  Demonstrator  of  Anatomy  in  the  Univ.  of  Maryland. 


TO  READERS  AND  CORRESPONDENTS. 


All  communications  intended  for  insertion  in  the  Original  Department  of  this 
Journal  are  only  received  for  consideration  with  the  distinct  understanding  that 
they  are  sent  for  publication  to  this  Journal  alone,  and  that  abstracts  of  them 
shall  only  appear  elsewhere  subsequently,  and  with  due  credit.  Gentlemen 
favoring  us  with  their  communications  are  considered  to  be  bound  in  honor  to 
a  strict  observance  of  this  understanding. 

Contributors  who  wish  their  articles  to  appear  in  the  next  number  are  requested 
to  forward  them  before  the  1st  of  May. 

Liberal  compensation  is  made  for  all  articles  used.  Extra  copies,  in  pamphlet 
form  with  cover,  will  be  furnished  to  authors  in  lieu  of  compensation,  provided 
the  request  for  them  be  written  on  the  manuscript. 

The  following  works  have  been  received  for  review :  — 

Das  Sauerstaff  Bediirfniss  des  Organisms  von  Dr.  P.  Ehrich.  Berlin  :  August 
Hirschwald,  1885. 

Die  Erkrankungen  des  Nabels  bei  Neugeboren,  von  Dr.  Ludwig  Furth.   Wien,  1884. 

Memoria  sulla  cura  del  l'Ectropia  inflammatorio  (escissione  congiuntiva  e  cauterizza- 
tione)  pel  Dott.  Raeffele  Castorani.    Napoli,  1884. 

Memoria  sull'  estrazione  Lineare  inferiore  della  cateratta  con  la  capsula  pel  Dott. 
Raeffele  Castorani.    Napoli,  1884. 

De  l'Aphasia  et  de  ses  diverses  formes  par  le  Doct.  Bernard,  ancien  interne  en 
Medecin  et  en  Chirurgie  des  hftpitaux  de  Paris.  Paris  :  A.  Delehaye  et  E.  Lecrosnier, 
1885. 

Traitement  de  la  diphtherie  et  angine  couenneuse  et  croup  par  le  Dr.  Marc  Jousset. 
Paris  :  J.  B.  Balliere  et  fils,  1885. 

De  la  resection  de  l'articulation  tibio-tarsienne  par  le  face  posteriore  dans  l'arthrite 
fongueuse,  par  le  Professor  Dr.  Liebrecht.    Bruxelles  :  A.  Moneraux,  1885. 

I? Acid  Phenique  et  la  Fi&vre  Typhoid  par  Albert  Robin.    Paris,  1885. 

The  Inhalation  Treatment  of  Diseases  of  the  Organs  of  Respiration,  including  Con- 
sumption. By  Arthur  Hill  Hassall,  M.D.  London,  Member  of  the  Royal  College 
of  Physicians,  etc.    London  :  Longmans,  Green  &  Co.^  1885. 

The  Revival  of  Ovariotomy  by  Sir  Spencer  Wells,  Bart.  London  :  J.  &  A.  Churchill. 

A  Code  of  Rules  for  the  Prevention  of  Infectious  and  Contagious  Diseases  in  Schools. 
London  :  J.  &  A.  Churchill,  1885. 

Saint  Bartholomew's  Hospital  Reports.  Edited  by  W.  S.  Chuch,  M.D.,  and  John 
Langton,  F.R.C.S.    London  :  Smith,  Elder  &  Co.,  1884. 

Paracentesis  Thoracis.    By  W.  Henry  White,  M.A.,  M.D.,  M.R.C.P.  London. 

The  Pathology  and  Etiology  of  Club-Foot.  By  Robert  W.  Parker  and  Samuel  G. 
Shattock.    London.  1884. 

Cullingworth  on  the  Operation  for  Rupture  of  the  Female  Perineum.  Reprint. 

Case  in  which  attacks  of  Intermittent  Tonic  Muscular  Spasm  immediately  followed 
by  complete  Temporary  Paralysis  have  frequently  and  periodically  recurred  during 
the  entire  life  of  the  Patient,  the  Health  in  the  intervals  being  Normal.  By  A.  Hughes 
Bennett,  M.D.,  Physician  to  the  Hospital  for  Epilepsy  and  Paralysis. 

Kussmaul's  Coma.    Reprint  from  the  Birmingham  Medical  Review,  Vol.  XVII. 

Fifteenth  Report  of  the  Hospital  for  Chinese  at  the  American  Episcopal  Commission. 
Shanghai,  1883. 

Supplement  to  the  Transactions  of  *the  Sei  I  Kwai,  or  Society  for  the  Advancement 
of  Medical  Science  in  Japan.  Transactions,  No.  37.  Supplement,  No.  2.  Tokio, 
February,  1885. 

A  Manual  of  Organic  Materia  Medica.  By  John  W.  Maisch,  Professor  of  Materia 
Medica  and  Botany  in  the  Philadelphia  College  of  Pharmacy.  Philadelphia  :  Lea 
Brothers  &  Co.,  1885. 


308 


TO  READERS   AND  CORRESPONDENTS. 


Lectures  on  the  Diseases  of  the  Nervous  System,  especially  in  Women.  By  S.  Weir 
Mitchell,  M.D.,  Member  of  the  National  Academy  of  Sciences,  Physician  to  the 
Orthopaedic  Hospital  and  Infirmary  for  Diseases  of  the  Nervous  System,  etc.  Second 
edition,  revised  and  enlarged,  with  five  plates.  Philadelphia  :  Lea  Brothers  &  Co., 
1885. 

A  Manual  for  the  Practice  of  Surgery.  By  Thomas  Bryant,  F.R.C.S.,  Senior  Sur- 
geon to,  and  Lecturer  on  Surgery  at  Guy's  Hospital.  Fourth  edition,  thoroughly  re- 
vised.   Philadelphia  :  Henry  C.  Lea's  Son  &  Co. 

Insanity  and  allied  Neuroses  :  Practical  and  Universal.  By  George  H.  Savage, 
M.D.,  M.R.C.P.    Philadelphia  :  Henry  C.  Lea's  Son  &  Co.,  1884. 

A  System  of  Practical  Medicine  by  American  Authors.  Edited  by  William  Pepper, 
M.D. ,  LL.D.,  Provost  and  Prof,  of  Theory  and  Practice  of  Medicine  in  the  University 
of  Pennsylvania.  Assisted  by  Louis  Starr,  M.D.,  Clin.  Prof,  of  Diseases  of  Children 
in  the  Hospital  of  the  University  of  Penna.  Vol.  I.  Pathology  and  General  Diseases. 
Philadelphia  :  Lea  Brothers  &  Co.,  1885. 

Topographical  Anatomy  of  the  Brain.  By  J.  C.  D Alton ,  M.D.,  Prof.  Emeritus  of 
Phvsiology  in  College  of  Phys.  and  Surgeons,  New  York.  Philadelphia  :  Lea  Brothers 
&Co.,  1885. 

The  Science  and  Art  of  Surgery.  By  John  Eric  Erichsen,  F.R.S.,  LL.D.,  F.R.C.S., 
Surgeon  Extraordinary  to  Her  Majesty  the  Queen.  Eighth  edition.  Revised  by  Mar- 
cus Beck,  M.S.  and  M.B.  Lond.    2  Vols.    Philadelphia  :  Lea  Brothers  &  Co.,  1885. 

The  Tear  Book  of  Treatment  for  18S4.    Philadelphia  :  Lea  Brothers  &  Co.,  1885. 

A  Manual  of  Human  Physiology,  including  Histology  and  Microscopical  Anatomy. 
By  Dr.  L.  Landois,  Professor  of  Physiology  in  the  University  of  Greifswald.  Trans- 
lated from  the  4th  German  edition,  with  additious.  By  William  Sterling,  M.D., 
Sc.D.,  Regius  Professor  of  the  Institutes  of  Medicine  in  the  University  of  Aberdeen. 
Vol.  I.    Philadelphia  :  P.  Blakiston,  Son  &  Co.,  1885. 

Bodily  Deformities  and  their  Treatment.  A  Hand-Book  of  Practical  Orthopaedics. 
By  Henry  Albert  Reeves,  Surgeon  to  the  Royal  Orthopaedic  Hospital,  etc.  With 
228  illustrations.    Philadelphia  :  P.  Blakiston,  Son  &  Co.,  1885. 

Dental  Surgery  for  Practitioners  and  Students.  By  Ashley  W.  Barrett,  M.B., 
M.R.C.S.,  L.D.S.,  Dental  Surgeon  to  the  London  Hospital.  Philadelphia  :  P.  Blakis- 
ton, Son  &  Co.,  1885. 

Consumption :  its  Natural  Causes,  Prevention,  and  Cure.  By  J.  M.  W.  Kitchen, 
M.D.    New  York  and  London  :  G.  P.  Putnam's  Sons,  1885. 

A  Hand-Book  of  Pathological  Anatomy  and  Histology,  with  an  Introductory  Lec- 
ture on  Post-mortem  Examinations,  and  the  Methods  of  Preserving  and  Examining 
Diseased  Tissues.  By  Francis  Delafield,  M.D.,  Professor  of  Pathology  and  Practi- 
cal Medicine  in  the  College  of  Physicians  and  Surgeons,  New  York  ;  and  T.  Mitchell 
Pruden,  M.D.,  Director  of  the  Physiological  and  Pathological  Laboratory  of  the 
Alumni  Association  of  the  College  of  Physicians  and  Surgeons.  New  York.  New  York  : 
Wm.  Wood  &  Co.,  1885. 

Kirke's  Hand-Book  of  Physiology.  Edited  by  W.  Mordant  Baker,  F.R.C.S.,  Sur- 
geon to  St.  Bartholomew's  Hospital,  and  Vincent  Dormer  Harris,  M.D.  London, 
Demonstrator  of  Physiology  at  St.  Bartholomew's  Hospital.  Eleventh  edition.  Vol.  I. 
New  York  :  Wm.  Wood  &  Co.,  1885. 

Diseases  of  the  Urinary  and  Male  Sexual  Organs.  By  William  T.  Belfield,  M.D. 
New  York  :  Wm.  Wood  &  Co.,  1885. 

A  Manual  of  the  Medical  Botany  of  North  America.  By  Lawrence  Johnson,  Lec- 
turer on  Medical  Botany  in  the  Medical  Department  of  the  University  of  the  City  of 
New  York.    New  York:  Wm.  Wood  &  Co.,  1S84. 

The  Therapeutics  of  the  Respiratory  Passages.  By  Prosser  James,  Lecturer  on 
Materia  Medica  and  Therapeutics  at  the  London"Hospital  Medical  College.  New  York  : 
Wm.  Wood  &  Co.,  1884. 

The  International  Encyclopaedia  of  Surgery.  Edited  by  John  Ashhurst,  Jr.,  M.D., 
Professor  of  Clinical  Surgery  in  the  University  of  Pennsylvania.  Vol.  V.  New  York  : 
William  Wood  &  Co.,  1884. 

A  Text-Book  of  Hygiene.  By  George  H.  Rohe,  M.D.,  Professor  of  Hygiene  in  the 
College  of  Physicians  and  Surgeons,  Baltimore.    Baltimore  :  Thomas  &  Evans,  1885. 

Manual  of  Nervous  Diseases,  and  an  Introduction  to  Medical  Electricity.  By  A.  B. 
Arnold,  M.D.,  Professor  of  Diseases  of  the  Nervous  System  and  Clinical  Medicine, 
College  of  Physicians  and  Surgeons,  Baltimore.    New  York  :  J.  H.  Vail  &  Co.,  1885. 

Annual  Report  of  the  Supervising  Surgeon-General  of  the  Marine  Hospital  of  the 
United  States  for  1884.    Washington  :  Government  Printing  Office,  18S4. 

Concerning  the  Climate  of  New  Mexico.  By  W.  Thornton  Parker,  M.D.  (Munich), 
Acting  Assistant-Surgeon  U.  S.  A. 

Conspectus  of  the  Medical  Colleges  of  America,  compiled  bv  the  Illinois  State  Board 
of  Health.    Revised  to  December  20,  1884.    Springfield,  Illinois,  1884. 

Official  Register  of  Physicians  and  Midwives.  By  the  Illinois  State  Board  of  Health, 
1877-1884.    Springfield,  Illinois,  1884. 


TO  READERS   AND  CORRESPONDENTS. 


309 


House  Drainage  in  New  Haven.  By  Alton  W.  Leighton,  Ph.B.,  M.D.  New 
Haven,  Ct. 

Johns  Hopkins  University.  Studies  from  the  Biological  Laboratory.  Vol.  III. 
No.  2.    Baltimore,  1884. 

Significance  of  Human  Anomalies.    By  Francis  J.  Shepherd,  M.D. 

Quarterly  Retrospect  of  Surgery.  Prepared  by  Francis  J.  Shepherd,  Surgeon  to 
Montreal  University. 

Cerebral  Localization  in  Relation  to  Insanity,  with  cases.  By  J.  M.  Carnochan, 
Member  of  the  Medico-Legal  Society  of  New  York.    New  York,  1884. 

The  Family  System  as  an  Accessory  Provision  for  our  Insane  Poor.  By  Henry  R. 
Steadman,  M.D.,  Boston. 

The  Hygiene  of  the  Nervous  System  and  Mind.  By  C.  H.  Hughes,  M.D.,  St.  Louis. 

An  Experimental  Study  of  Anaesthetics.  By  B.  A.  Watson,  A.M.,  M.D.,  of  Jersey 
City.    Philadelphia,  1884. 

Acetate  of  Lead  in  Ocular  Therapeutics.    By  David  De  Beck.    Cincinnati,  1884. 

The  Role  of  Bacteria  in  Infectious  Diseases.  By  Henry  O.  Marcy,  A.M.,  M.D., 
Boston.    Chicago,  1884. 

Aphonia  due  to  Chronic  Alcoholism.  By  E.  C.  Morgan,  A.B.,  M.D.,  Washington, 
D.  C.    Chicago,  1884. 

On  the  Necessity  of  Providing  for  the  Better  Education  of  Children  with  Defective 
Hearing  in  Public  Schools.    By  Samuel  Sexton.   New  York,  1884. 

Typhoid  Fever  and  Low  Water  in  Wells.  By  Henry  B.  Baker.  Lansing,  Michi- 
gan, 1885. 

The  Jenner  of  America.  An  Address  before  the  Philadelphia  County  Medical  Society. 
By  W.  M.  Welch,  M.D.   Philadelphia,  1885. 

Deterioration  of  Vision  in  School  Children.  By  S.  0.  Richey.  Concord,  New  Hamp- 
shire, 1885. 

Catarrhal  Mucous  Membrane.    By  R.  W.  Logan,  M.D. 

Experimental  Researches  on  Cicatrization  in  Bloodvessels.  By  N.  Senn,  M.D.,  of 
Milwaukee,  Wisconsin. 

The  Physiological  Action  of  Cocaine  on  the  Common  Frog,  with  Special  Reference 
to  its  Action  on  Organs  and  Tissues.  By  Hermann  Biggs,  A.M.,  M.D.,  New  York. 
Greifswald,  1S85. 

Report  of  Committee  on  School  Hygiene  in  Tennessee.  By  Daniel  F.  Wright, 
M.D.,  Tennessee,  1885. 

Proceedings  of  the  Kentucky  State  Medical  Society,  1884.    Louisville,  1885. 

Transactions  of  the  State  Medical  Society  of  Wisconsin,  1884.    Milwaukee,  1884. 

Fifth  Report  of  the  State  Board  of  Health,  Lunacy,  and  Charity  of  Massachusetts. 
Boston,  1884. 

Report  of  the  State  Lunatic  Hospital  at  Northampton  for  1884.    Boston,  1885. 
Report  of  the  State  Hospital  for  the  Insane,  Warren,  Pennsylvania. 
Report  of  the  Massachusetts  School  for  the  Feeble  Minded  at  South  Boston.  Boston, 
1885. 

Report  of  the  Manhattan  Eye  and  Ear  Hospital,  with  Throat  and  Nervous  Depart- 
ments.   New  York,  1883  and  1884. 

Seventh  Annual  Report  of  the  Trustees  of  the  Danver's  Lunatic  Asylum,  for  the 
year  ending  September  30, 1884.    Boston,  1885. 


The  following  Journals  have  been  received  in  exchange: — 

r«Xwo?.  Bibliothek  for  Larger.  Kronika  Lekarska.  Annali  Universali  di  Medecina 
e  Chirurgia.  Annali  Universali  di  Medecina  e  Chirurgie  (parte  revista).  Gazzetta 
degli  Ospitali.  Upsala  Lakareforenings  Forhandlingar.  Gazzetta  Medica  di  Torino. 
Rivisit.  Veneta  di  Sci.  Med.  Cronica  Medico-Quirurgica  dela  Habana.  Uniao  Medico. 
La  Union  Medica,  Caracas.  La  Medicina  Contemporanea.  Eco  Cientifico  de  las 
Villas. 

Allgemeine  Wiener  med.  Zeitung.  Archiv  fur  Gynsekologie.  Berliner  klinische 
Wochenschrift.  Centralblatt  fur  Chirurgie.  Centralblatt  fur  Gynakologie.  Central- 
blatt  fiir  klinische  Medicin.  Centralblatt  fur  die  medicinischen  Wissenschaften. 
Centralblatt  fiir  die  gesammte  Therapie.  Deutsches  Archiv  fiir  klinische  Medicin. 
Deutsche  medicinische  Wochenschrift.  Fortschritte  des  Medicin.  Medicinisch-Chirur- 
gisches  Centralblatt.  Monatsheft  fiir  prak.  Dermatol.  Wiener  med.  Presse.  Wiener 
Klinik.    Zeitschrift  fiir  physiol.  Chemie.    Zeitschrift  fiir  Klin.  Medicin. 

Annales  de  Dermatologie  et  de  Syphiligraphie.  Annales  de  Gynecologic  Annales 
des  Maladies  Genito-Urinaires.  Annales  des  Mai.  de  l'Oreille,  etc.  Annales  de  la 
Societe  de  Medecine  d'Anvers.  Archives  de  Med.  et  Pharm.  Militaires.  Archives  de 
Tocologie.  Archives  Generales  de  Medecine.  Bulletin  Generale  de  Therapeutique. 
Gazette  Hebdomadaire.  Gazette  Medicale  de  Nantes.  Gazette  Medicale  de  Paris. 
Gazette  Medicale  de  l'Orient.  Gazette  Hebdomadaire  de  Montpellier.  Journal  de 
Medecine  de  Paris.  L'Abeille  Medicale.  L'Encephale.  Le  Progres  Medical.  L'Union 


310 


TO  READERS  AND  CORRESPONDENTS. 


Medicale.  Revue  de  Chirurgie.  .  Revue  de  Medecine.  Revue  d'Otologie.  ,Revue  de 
Therapeutique.  Revue  des  Sciences  Medicales.  Revue  Medicale  Francaise  et  Etrangere. 
Revue  Mensuelle  de  Laryngologie.    Union  Medicale  et  Scientiflque  du  Nord-Est. 

The  Asclepiad.  Brain.  Braithwaite's  Retrospect.  British  MedicalJournal.  Dub- 
lin Journal  of  Medical  Science.  Edinburgh  Medical  Journal.  Glasgow  Medical  Jour- 
nal. Journal  of  Anatomy  and  Physiology.  Journal  of  Mental  Science.  Lancet. 
Liverpool  Medico-Chirurgical  Journal.  London  Medical  Record.  Medical  Chronicle. 
Medical  Times  and  Gazette.  Midland  Medical  Miscellany.  Ophthalmic  Review. 
Practitioner.  Quarterly  Journal  of  Insanity.  Australian  Medical  Journal.  Indian 
Medical  Gazette. 

Alienist  and  Neurologist.  Albany  Medical  Annals.  American  Druggist.  American 
Journal  of  Insanity.  American  Journal  of  Obstetrics.  American  Journal  of  Pharmacy. 
American  Journal  of  Science.  American  Medical  Digest.  American  Practitioner. 
Annals  of  Surgery.  Archives  of  Dentistry.  Archives  of  Pediatrics.  Atlanta  Medical 
and  Surgical  Journal.  Boston  Medical  and  Surgical  Journal.  Boston  Journal  of 
Chemistry.  Buffalo  Medical  and  Surgical  Journal.  Chicago  Medical  Journal  and 
Examiner.  Cincinnati  Lancet  and  Clinic.  Cincinnati  Medical  News.  College  and 
Clinical  Record.  Columbus  Medical  Journal.  Dental  Cosmos.  Denver  Medical  Times. 
Detroit  Lancet.  Druggists'  Circular.  Ephemeris.  Fort  Wayne  Journal  of  Medical 
Sciences.  Independent  Practitioner.  Journal  of  the  American  Medical  Association. 
Journal  of  the  Franklin  Institute.  Kansas  City  Medical  Record.  Kansas  City 
Medical  Index.  Louisville  Medical  News.  Maryland  Medical  Journal.  Medical  Age. 
Medical  Annals.  Medical  Chronicle.  Medical  Herald.  Medical  Summary.  Medical 
and  Surgical  Reporter.  Medical  Record.  Mississippi  Medical  Monthly.  Nashville 
Journal  of  Medicine  and  Surgery.  New  Orleans  Medical  and  Surgical  Journal,  and 
Journal  of  Mycology.  New  York  Medical  Journal.  North  Carolina  Medical  Journal. 
Northwestern  Lancet.  Obstetrical  Gazette.  Pacific  Medical  and  Surgical  Journal. 
Popular  Science  Monthly.  Pharmaceutical  Record.  Philadelphia  Medical  Times. 
Physician  and  Surgeon.  Quarterly  Compendium  of  Medical  Science.  Sanitarian. 
Sanitary  Engineer.  Southern  Medical  Record.  Southern  Practitioner.  St.  Louis 
Courier  of  Medicine.  St.  Louis  Medical  and  Surgical  Journal.  Texas  Record  of 
Medicine.  Therapeutic  Gazette.  The  Polyclinic.  Virginia  Medical  Monthly.  Weekly 
Medical  Review.  Western  Medical  Reporter.  Canadian  Practitioner.  Canada  Lancet. 
Canada  Medical  Record.  Canada  Medical  and  Surgical  Journal.  L'Union  Medicale 
du  Canada. 


Communications  intended  for  publication,  and  books  for  review,  should  be  sent 
free  of  expense,  directed  to  I.  Minis  Hats,  M.D.,  Editor  of  the  American  Journal  of  the 
Medical  Sciences,  care  of  Lea  Brothers  &  Co.,  Philadelphia.  Parcels  directed  as 
above,  and  (carriage  paid)  under  cover,  to  Messrs.  Nimmo  &  Bain,  Booksellers, No.  14 
King  William  Street,  Charing  Cross,  London,  will  reach  us  safely  and  without  delay. 

All  remittances  of  money  and  letters  on  the  business  of  the  Journal  should  be  ad- 
dressed exchisively  to  the  publishers,  Lea  Brothers  &  Co.,  No.  706  Sansom  Street. 

The  advertisement  sheet  belongs  to  the  business  departmentof  the  Journal,  and  all 
communications  for  it  must  be  made  to  the  publishers. 


CONTENTS 


THE  AMERICAN  JOURNAL 

OF 

THE  MEDICAL  SCIENCES. 
NO.  CLXXVIII.    NEW  SERIES. 


APRIL,  1885. 


ORIGINAL  COMMUNICATIONS. 
MEMOIRS  AND  CASES. 

ART.  PAGE 

I.  Membranous  Croup;  Diphtheritic  Croup;  True  Croup.  By  J.  Lewis 
Smith,  M.D.,  Clinical  Professor  of  Diseases  of  Children  in  Bellevue 
Hospital  Medical  College,  New  York,  etc.  etc  317 

II.  A  Statistical  Review  of  the  Operative  Measures  devised  for  the  Relief 
of  Pyloric  Stenosis.  By  Randolph  Winslow,  M.A.,  M.D.,  Demonstrator 
of  Anatomy  in  the  University  of  Maryland,  and  Professor  of  Surgery  in 
the  Woman's  Medical  College  of  Baltimore;  Surgeon  to  University  and 
Bay  View  Hospitals,  Baltimore     .       .  .       .       .       .       .  345 

III.  Report  of  a  Case  of  Partial  Pylorectomy.  By  J.  M.  Spear,  M.D.,  of 
Cumberland,  Md.  .       .       .       .  369 

IV.  Alcoholic  Paralysis.  By  Henry  Hun,  M.D.,  Lecturer  on  Nervous 
Diseases  in  the  Albany  Medical  College         .       .       .       .       .  .372 

V.  Fistulous  Communications  between  the  Intestines  and  the  Female  Geni- 
tal Canal.    By  H.  D.  Fry,  M.D.,  of  Washington,  D.  C.       .       .       .  388 

VI.  Laryngeal  Hemorrhage.  By  J.  W.  Gleitsmann,  M.D.,  Surgeon  to  the 
German  Dispensary,  and  Assistant  to  the  New  York  Polyclinic,  Throat 
and  Ear  Department,  New  York   ........  396 

VII.  The  Measurement  of  Refraction  by  the  Shadow-test,  or  Retinoscopy. 
By  Edward  Jackson,  A.M.,  M.D.,  of  Philadelphia,  Clinical  Assistant  in 
the  Eye  Department  of  the  Philadelphia  Polyclinic  and  the  Eye  and  Ear 
Department  of  the  Pennsylvania  Hospital      .       .       .     •  .       .       .  40# 


312 


CONTENTS. 


ART.  PAGE 

VIII.  A  Study  of  the  Subject  of  Spontaneous  Rupture  of  the  Membranes 
at  Full  Term  of  Gestation  preceding  the  beginning  of  Labor.    By  G.  W. 

H.  Kemper,  M.D.,  of  Muncie,  Indiana  .......  412 

IX.  A  Contribution  to  the  Pathology  of  Malarial  Fever.  By  W.  T.  Council- 
man, M.D.,  Associate  in  Pathology  Johns  Hopkins  University,  and  A.  C. 
Abbott,  M.D.,  of  Baltimore,  Md.  416 

X.  Observations  on  the  Cutaneous  and  Deep  Reflexes.  By  Philip  Coombs 
Knapp,  A.M.,  M.D.  (Harvard),  of  Boston  429 

XI.  Catalepsy  in  a  Child  three  years  old.  By  A.  Jacobi,  M.D.,  Clinical 
Professor  of  Diseases  of  Children  in  the  College  of  Physicians  and  Surgeons 

of  New  York   ..       .       .       .       .  450 

XII.  "Writers'  Cramp"  and  its  Treatment,  with  the  Notes  of  Several 
Cases.  By  Robert  Patterson  Robins,  M.D.,  Assistant  Demonstrator  of 
Clinical  Medicine  in  the  University  of  Pennsylvania       .  452 

XIII.  A  Correlation  Theory  of  Color-perception.  By  Charles  A.  Oliver, 
A.M.,  M.D.,  one  of  the  Ophthalmic  and  Aural  Surgeons  to  St.  Mary's 
Hospital,  Philadelphia  .       .       .       .  462 

XIV.  A  Case  of  Pernicious  Anaemia  ;  Recovery.  By  Guy  Hinsdale,  M.D., 

of  Philadelphia     .  482 

XV.  A  Case  of  One-sided  Transitory  Exophthalmos,  with  Undisturbed 
Function  and  Muscular  Movements  of  the  Eye  and  the  Coexistence  of 
Enophthalmos  or  Recession  of  the  Globe.  By  Robert  Sattler,  M.D., 
Ophthalmic  Surgeon  to  Cincinnati  Hospital,  etc.     .....  486 

XVI.  Hiatus  in  the  Anterior  Pillar  of  the  Fauces  of  the  Right  Side,  with 
Congenital  Absence  of  Tonsil  on  either  side.  By  J.  Herbert  Claiborne, 
Jr.,  M.D.,  Clinical  Assistant  to  the  Chair  of  Ophthalmology  in  the  New 
York  Polyclinic   .       .       .  .490 

XVII.  A  Case  of  Congenital  Ectropia  Lentis.  By  John  L.  Dickey,  A.M., 
M.D.,  of  Wheeling,  West  Virginia        .       .       .  -     .       .       .  .491 


REVIEWS. 

XVIII.  The  Principles  and  Practice  of  Gynaecology.  By  Thos.  Addis 
Emmet,  M.D.,  LL.D.,  Surgeon  to  the  Woman's  Hospital  of  the  State  of 
New  York ;  ex-President  of  the  American  Gynaecological  Society,  and 
New  York  Obstetrical  Society,  etc.  etc.  etc.  Third  edition,  thoroughly 
revised  ;  with  one  hundred  and  fifty  illustrations.    Philadelphia  :  Henry 

C.  Lea's  Son  &  Co.,  1884    493 

XIX.  Latest  Porro-Caesarean  Statistics,  with  an  Analysis  of  all  the  Cases. 
1.  "Porro's  Operation:   A  Supplement.    By  Clement  Godson,  M.D., 

Consulting  Physician  to  the  City  of  London  Lying-in  Hospital,"  etc., 
being  a  continuation  of  the  record  published  in  the  British  Medical 
Journal  of  January  26th,  1884.  Ibid.  January  17th,  1885,  pages 
120-122. 


CONTENTS. 


313 


ART.  PAGE 

2.  Sulla  Operazione  Porro.    Studia  critico-statistico,  del  Truzzi  Ettore. 

1°.  Assistente  presso  la  R.  Scuola  pareggiata  di  Ostetricia  in  Milano 

(Annali  Universali  di  Medicina  e  Chirurgia,  vol.  269,  Ottobre,  1884, 

pp.  387-394.    Novembre,  1884,  pp.  401-428). 
The  Porro  Operation,  a  Critico-statistical  Study.    By  Ettore  Truzzi, 

First  Assistant  of  the  Royal  Obstetrical  School  of  Milan  .        .        .  500 

XX.  A  Practical  Treatise  on  Disease  in  Children.  By  Eustace  Smith, 
M.D.,  F.R.C.P.  Lond.,  Physician  to  His  Majesty  the  King  of  the  Bel- 
gians, Physician  to  the  East  London  Children's  Hospital,  and  to  the  Vic- 
toria Park  Hospital  for  Diseases  of  the  Chest.  8vo.  pp.  844.  New  York  : 
William  Wood  &  Co.,  1884    504 

XXI.  Eleventh  Annual  Report  of  the  State  Commissioner  of  Lunacy  of  the 
State  of  New  York,  for  the  year  1883.  By  Stephen  Smith,  M.D.,  Com- 
missioner of  Lunacy.    8vo.  pp.  491.    New  York,  1884  ....  510 

XXII.  A  Text-Book  of  Hygiene.  A  Comprehensive  Treatise  on  the 
Principles  and  Practice  of  Preventive  Medicine  from  an  American  Stand- 
point. By  George  H.  Rohe,  M.D.,  Prof,  of  Hygiene,  College  of  Physi- 
cians and  Surgeons,  Baltimore;  Member  of  the  American  Public  Health 
Association  ;  of  the  Medical  and  Chirurgical  Faculty  of  Maryland,  etc.  etc. 
pp.324.    Baltimore:  Thomas  &  Evans,  1885    516 

XXIII.  Bodily  Deformities  and  their  Treatment,  a  Handbook  of  Practical 
Orthopaedics.  By  Henry  Albert  Reeves,  F.R.C.S.E.,  Surgeon  to  the 
Royal  Orthopaedic  Hospital,  to  the  East  London  Children's  Hospital,  and 
to  the  Hospital  for  Women ;  Senior  Assistant  Surgeon  and  Teacher  of 
Practical  Surgery  at  the  London  Hospital.  Small  8vo.  pp.  450.  Phila- 
delphia :  P.  Blakiston,  Son  &  Co.,  1885        .       .        .       .       .  .517 

XXIV.  Health  Reports. 

1.  Fourth  Annual  Report  of  the  State  Board  of  Health  of  New  York. 

Transmitted  to  the  Governor,  Feb.  21,  1884.    Pamphlet,  pp.  442. 
Albany,  1884. 

2.  Eighth  Annual  Report  of  the  Board  of  Health  of  the  State  of  New 

Jersey,  1884,  and  Report  of  the  Bureau  of  Vital  Statistics.  Pamphlet, 
pp.  375.    Trenton,  1884    523 

XXV.  The  International  Encyclopaedia  of  Surgery.  A  Systematic  Treatise 
of  the  Theory  and  Practice  of  Surgery  by  authors  of  various  nations. 
Edited  by  John  Ashhurst,  Jr.,  M.D.,  Professor  of  Clinical  Surgery  in 
University  of  Pennsylvania.  Vols.  IV.  and  V.  8vo.  pp.  xxiii.  987, 
xxxvii.  1207.    New  York  :  William  Wood  &  Co.,  1884        .       .  .526 

XXVI.  Topography  of  the  Anatomy  of  the  Brain.  By  J.  C.  Dalton,  M.D., 
Professor  Emeritus  of  Physiology  in  the  College  of  Physicians  and  Sur- 
geons, New  York,  and  President  of  the  College.  Three  volumes,  4to. 
Philadelphia:  Lea  Brothers  &  Co.,  1885    536 

XXVII.  Lectures  on  the  Principles  of  Surgery.  By  W.  H.  Van  Buren, 
M.D.,  LL.D.  (Yalen.),  formerly  Professor  of  the  Principles  and  Practice 
of  Surgery  in  the  Bellevue  Hospital  Medical  College,  etc.  8vo.  pp.  vii. 
588.    New  York:  D.  Appleton  &  Co.,  1884  .       ...       .       .  .538 


314 


CONTENTS. 


ART.  PAGE 

XXVIII.  A  New  Method  of  Treating  Chronic  Glaucoma,  based  on  Recent 
Researches  into  its  Pathology.  By  George  Lindsay  Johnson,  M.  A.,  M.B., 
B.C.  Cantab.,  Clinical  Assistant,  late  House-Surgeon  and  Chloroformist, 
Royal  Westminster  Ophthalmic  Hospital ;  Medical  and  Surgical  Regis- 
trar, etc.    8vo.  pp.  48.    London:  H.  K,  Lewis,  1884   ....  539 

XXIX.  Peruzzi  Dott.  Domenico.  Nota  sullaquinta  centuria  d'Ovariotomie 
in  Italia,  sulle  operazioni  affini  e  sulla  Ooforectomia. 

The  Fifth  Hundred  Ovariotomies  in  Italy,  together  with  kindred  Operations 
and  Oophorectomies.  By  Dr.  Domenico  Peruzzi,  of  Lugo.  Extracted  from 
the  Raccoglitore  Medico.  Series  iv.  vol.  xxii.  N.  12-13.  8vo.  pp.  27. 
Fiori,  1884   541 

XXX.  Diseases  of  the  Urinary  and  Male  Sexual  Organs.  By  W.  T.  Bel- 
field,  M.D.,  Author  of  Relations  of  Micro-Organisms  to  Disease  (Cart- 
wright  Lectures,  1883)  ;  Pathologist  to  the  Cook  County  Hospital;  Sur- 
geon to  the  Genito-Urinary  Department,  Central  Dispensary,  Chicago ; 
Physician  to  the  Oakwood  Retreat,  Geneva,  Wis.  ;  Professor  of  Micro- 
scopy, Chicago  College  of  Dental  Surgery.  New  York  :  Wm.  Wood  & 
Co.,  October,  1884    542 

XXXI.  Surgery  of  the  Urinary  Organs.  By  Sir  Henry  Thompson, 
F.R.C.S.,  M.B.  Lond.,  Professor  of  Surgery  and  Pathology  to  the  Royal 
College  of  Surgeons.    8vo.  pp.  147.    Philadelphia:  P.  Blakiston,  Son 

&  Co  544 

XXXII.  The  Ophthalmoscope  and  Lues.  By  Ole  B.  Bull,  M.D.  8vo.  pp. 
117.    Christiana:  P.  T.  Mailing,  1884  .       .        .  .       .       .  550 

XXXIII.  A  Practical  Treatise  on  Fractures  and  Dislocations.  By  Frank 
Hastings  Hamilton,  M.D.,  LL.D.,  late  Professor  of  Surgery  in  Bellevue 
Hospital  Medical  College,  New  York.  8vo.  pp.  xxxi.  1005.  Seventh 
American  edition.    Philadelphia:  Henry  C.  Lea's  Son  &  Co.,  1884       .  553 

XXXIV.  Injuries  and  Diseases  of  the  Jaws :  the  Jacksonian  Pri«e  Essay 
of  the  Royal  College  of  Surgeons  of  England,  1867.  By  Christopher 
Heath,  F.R.C.S.,  Holme  Professor  of  Clinical  Surgery  in  Universit}r 
College,  London,  etc.    Third  edition.    8vo.  pp.  xxi.  480.  Philadelphia  : 

P.  Blakiston,  Son  &  Co.,  1884   .  .554 

XXXV.  Medical  Diagnosis  :  A  Manual  of  Clinical  Methods.  By  J.  Gra- 
ham Brown,  M.D.,  Fellow  of  the  Royal  College  of  Physicians,  Edinburgh. 
Second  edition,  illustrated,  pp.  285.  New  York  and  London  :  Birming- 
ham &  Co.,  1884   555 

XXXVI.  Elements  of  Surgical  Diagnosis.  By  A.  Pearce  Gould,  F.R.C.S.  , 
Eng.;  Assistant  Surgeon  to  the  Middlesex  Hospital,  London;  Surgeon  to 
the  London  Temperance  Hospital,  and  to  the  Royal  Hospital  for  Dis- 
eases of  the  Chest.    24mo.  pp.  viii.  584.    Philadelphia:  Henry  C.  Lea's 
Son's  &  Co.,  1884 .       ....       .       .       .       .       .       .       .  555 

XXXVII.  The  Year  Book  of  Treatment  for  1884.  8vo.  pp.  308.  Phila- 
delphia: Lea  Brothers  &  Co.,  1885    556 


CONTENTS. 


315 


QUARTERLY  SUMMARY 

OF  THE 

IMPROVEMENTS  AND  DISCOVERIES  IN  THE 
MEDICAL  SCIENCES. 

Anatomy  and  Physiology. 


page 

Case  of  a  Hermaphrodite  aged  nine 
years  with  the  external  appear- 
ances of  a  Female,  in  whom  both 
Testicles  were  removed  from  the 
Labia  Majora.  By  Dr.  George 
Buchanan  .  .  .  .557 
Hypnotism.  By  M.  August  Voisin  557 
Pathological  Physiology  of  the  Su- 
pra-renal Capsule.    By  Tissoni  .  558 


The  Influence  of  Nervous  and  Mus- 
cular Work,  and  of  Fatigue  upon 
the  Tendon  Reflexes  and  Electro- 
Excitability  of  the  Muscles  in 
Man.    By  Dr.  J.  Orschansky  .  560 

New  Methods  for  Testing  Urine. 
By  Dr.  V.  Jaksch    .        .  .560 


Materia  Medica  and  Therapeutics. 


Antipyrin.  By  Huchard  .  .561 
Employment  of  Hydrochlorate  of 
Cocaine  in  Obstetrics.  By  Dr. 
Alphonse  Herrgott  .  .  .562 
Cerebral  Symptoms  from  Subcuta- 
neous Injection  of  Hydrochlorate 
of  Cocaine.  By  M.  Dujardin- 
Beaumetz         ....  562 


Thallin  as  an  Antipyretic.  By  Dr. 
C.  Alexander   .        .        .  .563 

Therapeutics  and  Action  of  Euphor- 
bia Pilulifera.    By  Marset       .  563 

New  Apparatus  for  Transfusion  of 
Blood.    By  Dr.  Vleminckx      .  563 


Medicine. 


The  Etiology  of  Asiatic  Cholera. 
By  Ceci  and  Klebs   .       .       .  564 

New  Therapeutic  Researches  upon 
the  Asiatic  Cholera  of  1884.  By 
Dr.  M.  Semmola      .       .  .565 

Intra-Peritoneal  Styptic  and  Seda- 
tive Injection  in  Cholera.  By  Dr. 
Benj.  W.  Richardson       .        .  567 

Contribution  to  the  Study  of  Lar- 
yngo-Typhus.  By  Dr.  Paul  Koch  568 

Carbolic  Acid  in  Typhoid  Fever. 
By  Dr.  Albert  Robin       .        .  568 

A  Case  of  Acute  Rheumatic  Poly- 
arthritis in  a  Child  thirteen  weeks 
old  569 

Pulmonary  Manifestation  in  Rheu- 
matism.   By  M.  Lebreton        .  570 


The  Therapeutic  Value  of  Iodoform 
in  the  Treatment  of  Gout.  By 
Dr.  Testa         .        .        .  .570 

Persistent  Hiccough  cured  by  Ja- 
borandi.    By  Dr.  Pagenstecher  571 

Inoculation  of  Tuberculosis  in  a 
Woman.    By  E.  A.  Tscherning  571 

Spontaneous  Peritonitis.  By  Prof. 
E.  Leyden       .       .       .  .572 

Nephritis  and  Uterine  Epithelioma. 
By  Dr.  E.  Lanceraux       .  .573 

Occlusion  of  both  Ureters  by  Renal 
Calculi.  Anuria  for  Twenty-three 
Consecutive  Days.  By  Dr.  Ernst 
Bischoff  575 


310 


CONTENTS. 


Surgery. 


Cancer  of  the  Tongue.  By  Mr.  F. 
Bowrenian  Jessett    .        .  .  .577 

Malignant  Stricture  of  the  (Esopha- 
gus. By  Mr.  Charters  J.  Sym- 
onds        .        .       .        .  .578 

Penetrating  Wound  of  the  Poste- 
rior Wall  of  the  Stomach — Su- 
ture and  Recovery.  By  G.  Til- 
ing .       .        .       .       .       .  578 

Incised  Wound  of  the  Anterior 
Wall  of  the  Stomach.  By  Dr. 
Facilides-Reichenbach      .  .579 

Excision  of  the  Caecum  for  Epithe- 
lioma ;  Death  on  the  thirteenth 
day.  By  Dr.  Walter  White- 
head  580 

Urethral  Fistules  of  the  Penis  and 
their  Treatment.  By  Dr.  Robert  583 


PAGE 

Intraperitoneal  Rupture  of  the 
Bladder.    By  Dr.  Sonnenburg  .  583 

Litholapaxy  performed  on  a  Ta- 
betic Patient.  By  Dr.  Fiirsten- 
heim        .  584 

Simultaneous  Double  Distal  Liga- 
ture of  the  Carotid  and  Subcla- 
vian Arteries  for  High  Innomi- 
nate Aneurism.  By  Mr.  Richard 
Barwell  584 

The  Removal  of  the  Marrow  of 
Long  Bones  and  the  Application 
of  Corrosive  Sublimate  Solution 
and  Iodoform,  as  a  Treatment  of 
Osteomyelitis.  By  Dr.  Chas.  B. 
Keetley  586 


Ophthalmology  and  Otology. 


Ocular  Affections  in  Locomotor 
Ataxia.    By  M.  Galezowski     .  587 

Amaurosis  due  to  Anaesthesia  of 
the  Optic  Nerve.  By  M.  Dia- 
noux        ....  .588 

Hypodermic  Injection  of  Pilocarpin 


in  Affections  of  the  Labyrinth. 

By  Prof.  Adam  Politzer  .  .588 
Exfoliation  of  the  Cochlea  without 

Loss  of  Hearing.  By  Prof.Griiber  589 
Treatment  of  Deaf-mutism  caused 

by  Auricular  Compression.  By 

Dr.  Boucher  on.       .       .  .589 


Midwifery  and  Gynaecology. 


Corrosive  Sublimate  in  Obstetrics. 
By  Drs.  Stadtfeldt  and  Stenger  591 

A  Successful  Case  of  Laparo-Ely- 
trotomy.  By  Dr.  Alex.  J.  C. 
Skene  591 

Prophylaxis  of  Post-partum  Hem- 
orrhage. By  Dr.  Glynn  Whittle  592 


Treatment  of  the  Umbilicus  in  the 
New-born.  By  Crede  and  We- 
ber .       .        .       .        .  .593 

A  Case  of  Hysterectomy.  By  M. 
Terrier  593 

Extirpation  of  the  Uterus.  By  Dr. 
W.  A.  Duncan.        .       .  .594 


Medical  Jurisprudence  and  Toxicology. 

Ingestion  of  an  enormous  Dose  of        i     producing  Toxic  Symptoms.  By 
Sulphate  of  Strychnine  without        |     Dr.  Lardier      .       .       .  .597 


THE 


AMERICAN  JOURNAL 
OF  THE  MEDICAL  SCIENCES 

FOR  APRIL,   1  885. 


Article  I. 

Membranous  Croup  ;  Diphtheritic  Croup  ;  True  Croup.  By  J.  Lewis 
Smith,  M.D.,  Clinical  Professor  of  Diseases  of  Children  in  Bellevue  Hospital 
Medical  College,  New  York,  etc.  etc. 

The  term  pseudo-membranous  laryngitis,  or  laryngo-tracheitis,  or  true 
croup  is  applied  to  a  common  and  fatal  disease,  the  essential  anatomical 
character  of  which  is  inflammation  of  the  larynx,  or  larynx  and  trachea, 
with  the  formation  of  a  pseudo-membrane  upon  its  surface.  It  occurs 
most  frequently  between  the  ages  of  two  and  twelve  years,  but  infancy 
after  the  age  of  six  months  and  early  manhood  are  not  exempt  from  it. 
For  brevity  I  shall  use  the  term  croup  in  the  following  pages  to  indicate 
this  form  of  inflammation,  although  recognizing  another  form  of  croup, 
the  spasmodic  or  catarrhal,  in  which  no  pseudo-membrane  occurs. 

Etiology. — Wherever  diphtheria  prevails  as  an  endemic  or  epidemic,  it 
is  well  known  that  a  large  majority  of  the  cases  of  membranous  croup  are 
local  manifestations  of  this  disease,  and  this  inflammation  is  therefore  in 
such  localities  commonly  designated  diphtheritic  croup.  Physicians  have 
endeavored  to  discriminate  between  croup  due  to  diphtheria  and  that  from 
other  causes  ;  but  whatever  the  cause,  the  anatomical  characters,  the 
clinical  history,  and  the  required  treatment  are' so  nearly  identical  that 
attempts  to  differentiate  the  disease  when  produced  by  other  agencies 
than  diphtheria  from  that  due  to  diphtheria,  have  proved  futile  and 
unsatisfactory  in  localities  where  diphtheria  occurs,  except  'in  a  few 
instances,  as,  for  example,  when  croup  has  been  manifestly  caused  by 
swallowing  or  inhaling  some  irritating  agent. 

Inflammation  of  the  laryngeal  and  tracheal  surface,  whatever  its  cause, 
whenever  it  reaches  a  certain  grade  of  severity,  may  be  attended  by  the 
No.  CLXXVIII  April,  1885.  21 


318         Smith,  Membranous,  Diphtheritic,  and  True  Croup.  [April 


exudation  of  fibrin  and  the  formation  of  a  pseudo-membrane,  but  such 
a  result  more  frequently  occurs  in  the  inflammation  caused  by  diphtheria 
than  in  that  produced  by  other  agencies.  In  diphtheria  a  moderate 
laryngo-tracheitis  is  attended  by  the  pseudo-membranous  formation. 

The  percentage  of  cases  of  diphtheria  in  which  the  larynx  becomes 
implicated  and  croup  occurs,  varies  in  different  epidemics  and  in  different 
seasons  and  localities.  In  epidemics  of  a  mild  type,  the  cases  appear  to 
be  fewer  in  which  the  larynx  is  involved  than  in  epidemics  of  a  severe 
form.  In  New  York  the  percentage  is  large.  From  December  1,  1875, 
to  July,  1878,  I  preserved  records  of  all  the  cases  of  diphtheria  which 
came  under  my  notice.  The  number  was  104,  and  in  twenty-five  of  these, 
or  about  one  in  four,  croup  occurred,  producing  the  usual  obstructive 
symptoms,  and  constituting  the  chief  source  of  danger.  During  the  two 
and  a  half  years  embraced  in  these  statistics  the  disease  was  usually  severe. 
In  the  last  five  years  amelioration  has  occurred  in  the  type  of  diphtheria 
in  this  city,  and  the  proportion  of  croup  cases  has  not  been  so  large. 

So  commonly  is  membranous  croup,  when  occurring  in  a  locality  where 
diphtheria  is  endemic  or  epidemic,  a  local  manifestation  of  diphtheria, 
that  physicians  in  such  localities  come  to  regard  every  case  of  this  disease 
of  the  larynx  as  produced  by  the  diphtheritic  poison.  In  New  York 
physicians  scarcely  recognize  any  other  form  of  membranous  croup.  It 
is  well,  therefore,  briefly  to  recall  the  evidences  that  croup  in  a  certain 
proportion  of  cases  results  from  other  causes  than  diphtheria.  The  occur- 
rence of  croup  in  localities  where  diphtheria  is  unknown,  .of  course,  indi- 
cates the  operation  of  some  other  agency  than  the  diphtheritic  poison. 
Thus,  in  1842,  before  diphtheria  was  established  in  this  country,  Dr.  John 
Ware,  of  Boston,  published  his  well-known  paper  on  croup,  and  in  74  of 
the  75  cases  embraced  in  his  statistics  the  membranous  exudation  was 
present  upon  the  faucial  surface.  The  statistics  relating  to  the  introduc- 
tion of  diphtheria  into  New  York  City,  and  the  recorded  death  statistics 
of  this  city,  have  been  annually  published,  and  each  year  more  or  fewer 
deaths  from  croup  have  been  reported.  The  first  death  from  diphtheria 
in  this  century,  within  the  city  limits,  certified  by  a  physician,  was  that 
of  a  German  woman,  at  638  Hudson  Street,  on  February  15,  1852.  Two 
other  fatal  cases  occurred  in  1857,  and  since  then  the  deaths  from  croup 
and  diphtheria  have  been  as  shown  in  the  following  table : — 


Year. 

Croup. 

Diphtheria. 

Year. 

Croup. 

Diphtheria 

1858  . 

.     .  478 

5 

1867  . 

.    .  338 

251 

1859  . 

.    .  622 

53 

1868  . 

.    .  342 

276 

1860  . 

.    .  599 

422 

1869  . 

.    .  483 

328 

1861  . 

.     .  460 

453 

1870  . 

.    .  421 

308 

1862  . 

.    .  685 

594 

1871  . 

.    .  466 

238 

1863  . 

.    .  908 

981 

1872  . 

.    .  675 

446 

1864  . 

.    .  754 

781 

1873  . 

.    .  732 

1151 

1865  . 

.    .  449 

534 

1874  . 

.    .  594 

1665 

1866  . 

.    .  368 

435 

1875  . 

.    .  758 

2329 

Since  1875  weekly  bulletins  were  issued  instead  of  the  annual  reports. 


1885.]     Smith,  Membranous,  Diphtheritic,  and  True  Croup.  819 


Thus,  in  the  first  years  after  the  introduction  of  diphtheria,  the  deaths 
assigned  to  croup  so  greatly  outnumbered  those  of  diphtheria,  as  in  1858, 
when  five  died  of  diphtheria  and  four  hundred  and  seventy-eight  of  croup, 
that  it  is  evident  that  most  of  the  cases  of  croup  in  those  years  were 
attributable  to  other  causes  than  diphtheria.  Since,  as  we  have  stated, 
any  inflammation  of  the  surface  of  the  larynx  and  trachea,  if  sufficiently 
intense,  may  produce  a  pseudo-membrane,  croup  may  occur  as  a  primary 
disease,  and  as  a  complication  of  various  maladies.  According  to  my 
observations  in  New  York  City,  the  chief  causes  of  croup,  arranged  in 
the  order  of  frequency,  would  be  about  as  follows  :  diphtheria,  "  taking 
cold,"  measles,  pertussis,  scarlatina,  typhoid  fever,  irritating  inhalations. 
I  have,  elsewhere,  related  cases  of  scarlet  fever  of  severe  type,  in  which 
a  thin  film  of  pseudo-membrane  was  found  upon  the  surface  of  the  larynx 
and  trachea,  and  there  was  no  other  lesion  to  indicate  that  diphtheria  had 
supervened.  The  croup  was,  to  all  appearances,  caused  by  the  scarlatinous 
and  not  the  diphtheritic  poison.  The  following  was  a  case  in  which  croup 
was  apparently  idiopathic,  and  produced  by  that  common  cause  of  inflam- 
mations of  mucous  surfaces,  to  wit,  exposure  to  sudden  atmospheric 
changes : — 

Case — At  midnight,  on  October  22d,  1884,  I  was  summoned  to  a 
child  aged  25  months,  who  had  been  in  the  street  till  nearly  nightfall,  when 
the  weather  suddenly  became  much  cooler,  and  he  was  brought  home.  At 
11.45  P.  M.  he  awoke  with  a  harsh  voice  and  croupy  cough  so  as  to  alarm 
the  family.  I  found  the  axillary  temperature  normal,  but  the  fauces  were 
injected,  and  the  diagnosis  was  made  of  spasmodic  or  catarrhal  croup. 
Emesis  was  produced  by  syrup  of  ipecacuanha ;  the  croup  kettle,  and  a 
mixture  of  potassium  chlorate  and  ammonium  chloride  were  ordered. 

On  the  following  day  he  walked  around  the  room  and  seemed  better, 
but  the  inhalation  of  the  vapor  of  lime  from  the  croup  kettle  was  continued. 
At  7  P.  M.  the  symptoms  became  aggravated,  the  cough  was  frequent  and 
hoarse,  temperature  (axillary)  100-|o,  pulse  120,  and  respiration  noisy. 
At  my  visit  the  post-clavicular,  supra-sternal,  infra-mammary,  and  epigas- 
tric regions  were  depressed  in  each  inspiration,  though  only  in  a  moderate 
degree ;  face  flushed,  fauces  injected  but  without  pseudo-membrane.  The 
aspect  was  now  more  serious  on  account  of  the  increasing  dyspnoea.  The 
pulse  was  strong,  and  no  pseudo-membrane  was  visible  ;  the  temperature, 
in  the  groin,  was  scarcely  100°.  Emesis  had  been  produced  before  my 
arrival,  and  in  the  matter  vomited  was  a  pseudo-membrane  with  ragged 
edges,  and  about  one-half  an  inch  in  length ;  examined  within  an  hour 
subsequently  under  the  microscope,  it  was  found  to  consist  of  fibrilhe, 
evidently  fibrous,  some  of  them  wavy,  and  inclosing  many  pus-cells.  Ten 
grains  of  calomel  were  placed  on  the  tongue,  and  inhalations  of  the  follow- 
ing were  almost  constantly  employed  by  the  steam  atomizer : — 

R. — Liq.  potassae,  gij  ; 

Aq.  calcis,  ^xij.  Misce. 

On  the  following  day  the  respiration  was  easier,  and  within  twenty 
hours  the  patient  had  so  far  convalesced  as  to  be  out  of  danger.  There 
had  been  no  case  of  diphtheria  in  the  house,  nor  recently,  as  far  as  I  could 
learn,  in  the  immediate  neighborhood. 


320         Smith,  Membranous,  Diphtheritic,  and  True  Croup.  [April 


That  this  was  a  local  disease,  non-specific,  and  quite  distinct  from  the 
croup  of  diphtheria,  cannot,  I  think,  be  doubted. 

In  considering  the  etiology  of  croup,  and  recognizing  diphtheria  as  by- 
far  its  most  common  cause,  wherever  the  latter  disease  prevails,  an  inter- 
esting theory  is  suggested,  to  which  Heubner  alludes,  who  affirms  that 
inflammations,  even  with  the  characteristic  membranous  exudation,  may 
be  set  up  without  the  micrococci  and  then  inoculation  by  micrococci  occur, 
and  "induce  the  general  disease"  ("Die  experimentelle  Diphtheria,'* 
Leipzig,  1883,  quoted  in  Ziegler's  Path.  Anat.,  part  ii.  paragraph  444,  Wm, 
Wood  &  Co.,  1884).  The  point  alluded  to  is  that  inflammations  arising 
from  other  causes  than  diphtheria  now  and  then  become  intensified,  and 
rendered  more  protracted  and  dangerous  by  the  reception  of  the  diphthe- 
ritic virus  after  the  inflammations  are  established,  In  support  of  this 
opinion  it  is  well  known  by  all  who  have  had  much  experience  with  diph- 
theria, that  those  surfaces  are  prone  to  be  attacked  by  the  specific  in- 
flammation that  are  already  irritated  or  inflamed  when  diphtheria  is 
contracted.  Hence  the  occurrence  of  the  pseudo-membrane  on  recent 
wounds,  upon  the  eyelids  in  cases  of  catarrhal  conjunctivitis,  upon  the 
uterine  surface  after  parturition,  and  upon  the  laryngeal,  tracheal,  and 
bronchial  surfaces,  if  they  are  already  inflamed  as  in  measles. 

Scarlatina  is  so  often  complicated  by  diphtheria  that  there  seems  to  be 
a  close  affinity  between  the  two  diseases.  It  is  a  very  common  observa- 
tion in  New  York  city  that  scarlet  fever  continues  two  or  three  days,  in 
its  usual  form,  when  the  symptoms  become  suddenly  aggravated  and  the 
aspect  of  the  disease  more  severe.  On  inspecting  the  fauces  a  pseudo- 
membrane  is  discovered  covering  this  region,  and  it  probably  appears  also 
upon  the  nasal  surface.  Although  severe  scarlatinous  inflammation  may 
cause  a  fibrinous  exudation,  yet  that  diphtheria  has  supervened  upon 
scarlet  fever  in  a  considerable  proportion  of  cases  which  have  the  above 
history  cannot,  I  think,  be  doubted.  In  a  few  instances  in  my  practice 
(4)  the  fact  that  scarlet  fever  was  complicated  by  true  diphtheria,  and  the 
scarlatinous  inflammations,  first  in  order,  were  intensified  by  the  presence 
and  influence  of  the  diphtheritic  poison,  was  shown  by  the  occurrence  of 
diphtheria  without  scarlet  fever  in  other  members  of  the  family. 

In  accordance  with  the  above  law  we  may  assume  that  a  child  who  has 
laryngo-tracheitis,  so  common  from  taking  cold  and  manifested  by  cough 
and  hoarseness,  is  more  prone  to  have  diphtheritic  croup  than  is  one  whose 
air-passages  are  in  their  normal  state  when  diphtheria  commences.  A 
supposed  error  of  diagnosis  is  often  made  by  physicians,  always  to  their 
discredit,  who  diagnosticate  catarrhal  laryngitis,  but  find,  after  two  or 
three  days,  that  their  patients  really  have  diphtheritic  croup.  A  consid- 
erable number  of  such  instances  have  come  to  my  notice,  always  with  the 
ill-will  of  families  towards  their  physicians.    Now  it  seems  to  me  that  in 


1885.]     Smith,  Membranous,  Diphtheritic,  and  True  Croup. 


321 


many  of  these  cases  the  physicians  have  been  right  in  their  first  diagnosis, 
and  diphtheritic  croup  supervened  on  the  catarrhal  inflammation. 

Another  point  relating  to  the  etiology  of  diphtheritic  croup  requires 
notice.  Many  physicians,  who  have  had  ample  opportunities  to  observe 
diphtheria,  believe  that  the  common  way  in  which  diphtheritic  croup 
begins  is  as  follows :  The  faucial  or  nasal  surface  is  first  affected, 
becoming  covered  by  the  pellicular  exudation,  and  during  inspiration 
particles  of  the  pseudo-membrane,  containing  the  specific  principle,  being 
detached,  lodge  in  the  larynx.  At  the  point  of  inoculation  the  specific 
inflammation  arises  and  extends.  This  may  be  the  manner  in  which  the 
croup  of  diphtheria  begins  in  certain  cases,  but  it  certainly  does  not 
apply  to  a  considerable  number  of  patients.  Thus  both  the  faucial  and 
nasal  pseudo-membranes  may  be  treated  every  second  or  third  hour  from 
the  time  of  their  formation  with  the  best  disinfectants  which  we  possess, 
so  as  to  destroy  all  the  micrococci  in  them  and  render  them  an  inert 
mass,  and  yet  croup  not  infrequently  occurs  during  the  progress  of  the 
case.  Again,  in  certain  cases  croup  begins  at  the  commencement  of  the 
diphtheritic  attack.  The  laryngitis  commences  as  early  as  the  pharyn- 
gitis, and  therefore  does  not  result  from  it.  Sometimes  the  inflammation 
of  the  air-passages  is  from  the  first  the  predominant  lesion,  the  pharyn- 
gitis being  subordinate  or  even  trivial.  Thus  a  boy  of  two  years,  ten 
months,  whom  I  attended,  died  of  croup  lasting  about  four  days.  He 
lived  in  the  suburbs  of  the  city,  where  the  houses  were  scattered,  and 
where  there  had  been  no  recent  diphtheria.  The  attack  began  with 
hoarseness,  which  gradually  increased  to  a  fatal  obstruction  in  the  air- 
passages.  Close  and  repeated  inspection  of  the  fauces  revealed  only  red- 
ness and  some  swelling  of  the  parts  that  were  visible,  and  the  symptoms 
indicated  but  slight  coryza.  The  diphtheritic  nature  of  the  disease  was 
rendered  certain  by  the  occurrence  of  diphtheria  in  its  usual  form,  in  the 
two  nurses  immediately  after  the  death  of  the  child.  In  this  case  croup 
began  at  the  beginning  of  the  sickness,  and  it  is  evident  from  the  history 
and  the  lesions  that  the  contagium  was  not  transferred  to  the  larynx  from 
any  of  the  other  surfaces.  In  view  of  the  number  of  such  cases  I  see  no 
propriety  in  assigning  to  diphtheritic  croup  a  mode  of  origin  different 
from  that  of  other  diphtheritic  inflammations.  But  the  possibility,  and 
perhaps,  probability,  in  some  instances  of  an  auto-infection  we  will  not 
deny. 

Anatomical  Characters  It  is  important  to  acquaint  ourselves  with 

the  anatomical  characters  of  croup,  especially  with  the  nature  of  the 
pseudo-membrane,  that  we  may  know  what  measures  to  employ  in  order 
to  remove  it  and  prevent,  as  far  as  possible,  the  laryngeal  stenosis  from 
which  so  many  perish.  The  surface  of  the  larynx,,  trachea,  and,  in 
severe  cases,  that  of  the  bronchial  tubes,  is  hyperaemic  and  swollen,  and 


322 


Smith,  Membranous,  Diphtheritic,  and  True  Croup.  [April 


the  inflammatory  action  involves  more  or  less  the  submucous  connective 
tissue,  causing  infiltration  or  oedema.  The  relation  of  the  exudation  to 
the  mucous  surface  varies  according  to  the  kind  of  epithelium  present. 
Where  the  epithelium  is  of  the  flat  or  squamous  variety,  the  fibrinous  ex- 
udation from  the  bloodvessels  is  poured  out  around  the  epithelial  cells, 
which  perish.  If  the  inflammation  extend  more  deeply,  the  underlying 
connective  tissue  is  also  embraced  in  the  coagulation  and  perishes.  Prof. 
Ziegler  of  Tubingen,  who  has  made  repeated  microscopic  examinations 
of  the  pseudo-membrane,  says  :  "  It  sometimes  happens  that  the  dead 
epithelial  cells  become  saturated  with  the  exuded  liquid  and  than  pass 
into  a  peculiar  condition  of  rigidity  akin  to  coagulation.  The  seat  of 
this  change  appears  to  the  naked  eye  as  a  dull,  raised,  grayish  patch  sur- 
rounded by  red  and  swollen  mucous  membrane.  The  exudation  is  rich 
in  albumen  and  the  transformed  cells  take  on  the  appearance  of  a  kind  of 
coarse  mesh-work,  almost  or  altogether  devoid  of  nuclei."  This  is 
superficial  diphtheritis,  and  Prof.  Ziegler  next  describes  deep  or  paren- 
chymatous diphtheritis  as  follows  :  "  It  is  characterized  by  the  coagula- 
tion, not  merely  of  the  epithelium,  but  also  of  the  underlying  connective 
tissue.  The  affected  patch  is  swollen  and  assumes  a  whitish  or  grayish 
tint,  the  discoloration  extending  through  the  epithelium  to  the  connective 
tissue  structures.  The  epithelium  in  some  cases  is  lost  altogether,  and 
then  the  diphtheritic  patch  consists  of  dead  connective  tissue  only.  .  .  . 
The  dead  tissue  is  separated  from  the  living  by  a  zone  of  cellular  inflam- 
mation. Fibrinous  filaments  are  seen  here  and  there  through  the  mass. 
The  lymphatics  in  the  neighborhood  contain  coagula  and  leucocytes.', 

Squamous  epithelium  covers  the  nostrils,  buccal  cavity,  fauces,  the 
larynx  upon  and  above  the  superior  vocal  cord,  with  the  exception  of  its 
anterior  aspect.  The  pseudo-membrane  therefore  upon  all  these  surfaces 
lined  with  this  form  of  epithelium  consists  of  the  exudate  from  the  blood 
which  surrounds  and  permeates  the  epithelium,  or  epithelium  and  subja- 
cent connective  tissue.  These  two  distinct  elements,  that  poured  out 
from  the  bloodvessels  and  the  normal  tissue  of  the  mucous  surface  now 
dead,  incorporated  in  one  mass,  therefore  constitute  the  pseudo-mem- 
brane. Its  intimate  relation  with  the  surrounding  living  tissue  is  such 
that  we  cannot  detach  it  without  lacerating  the  latter  and  causing 
bleeding. 

The  anterior  aspect  of  the  larynx  from  the  middle  of  the  epiglottis 
downward,  all  that  part  of  the  larynx  below  the  superior  vocal  cord,  the 
entire  trachea,  and  the  bronchial  tubes,  are  lined  by  columnar  epithelium. 
Whenever  this  variety  of  epithelium  is  present,  the  exudate  from  the 
blood  does  not  become  incorporated  with  the  mucous  membrane,  but 
escapes  to  the  surface  and  coagulates  in  a  layer  over  it.  It  is  therefore 
loosely  adherent  to  the  underlying  tissues,  being  attached  to  it  by  some 
fibrinous  threads,  and  when  it  is  peeled  off,  the  hyperasmic  and  swollen 


1S85.]     Smith,  Membranous,  Diphtheritic,  and  True  Croup. 


323 


mucous  membrane  is  seen  underneath  in  its  entirety,  unless,  as  is  com- 
monly the  case,  a  considerable  part  of  its  epithelium  has  been  shed  and 
been  expectorated.  The  loose  attachment  of  the  pseudo-membrane  in  the 
trachea  and  bronchial  tubes  is  of  the  greatest  significance  in  its  relation 
to  tracheotomy. 

I  wish  in  this  connection  to  call  attention  to  the  confusion  which  may 
occur  in  the  use  of  the  terms  diphtheritic  and  croupous,  as  employed  by 
pathologists  on  the  one  hand,  and  clinical  observers  or  practitioners  on 
the  other.  Pathologists,  following  Virchow,  designate  the  inflammation 
diphtheritic  when  the  epithelium  and  underlying  tissues  remaining  in 
situ  are  blended  with  the  exudate  and  become  a  part  of  the  pseudo- 
membrane,  whatever  may  be  the  cause  of  the  inflammation,  and  they 
designate  the  inflammation  croupous,  whatever  its  cause,  when  the 
exudate  escapes  to  the  surface  of  the  mucous  membrane,  as  in  the  trachea 
and  bronchial  tubes,  and  coagulates  upon  it.  Therefore,  in  all  cases  of 
pseudo-membranous  inflammation  of  the  air-passages,  even  that  due  to 
"  taking  cold,"  or  to  inhalation  of  an  irritating  vapor,  they  term  the 
laryngitis  diphtheritic,  since  in  the  larynx  the  exudate  is  incorporated 
with  the  mucous  membrane,  while  the  pseudo- membranous  tracheitis  or 
bronchitis  in  the  same  patient  is  termed  croupous,  since  the  exudate 
lies  upon  the  surface.  Practitioners,  on  the  other  hand,  apply  the  term 
diphtheritic  to  all  inflammations  which  occur  as  local  manifestations  of 
the  specific  disease,  diphtheria,  and  only  to  such  inflammations,  whatever 
may  be  their  form,  whether  pseudo-membranous  or  catarrhal. 

The  epithelial  cells  embraced  in  the  pseudo-membrane  undergo  a 
histological  change.  We  have  stated  Ziegler's  remark  that  they  are  per- 
meated by  the  exudate  of  the  blood.  Cornil  and  Ranvier  say,  "  Wagner 
admits  the  fibrinous  degeneration  of  the  cells.  .  .  We  have  verified 
the  description  given  by  Wagner,  but  we  would  conclude  that  the  cells 
are  filled  with  a  material  which  approaches  mucin  rather  than  fibrin." 
In  the  first  week,  the  pseudo-membrane  forms  more  rapidly,  and  is 
usually  thicker  and  more  extended,  producing  dyspnoea  more  quickly 
than  when  it  forms  in  the  declining  stage  of  the  disease.  If  the  mem- 
brane be  detached  by  the  forcible  coughing  of  the  patient,  it  is  usually 
quickly  reproduced  unless  the  diphtheria  be  in  its  advanced  stage  and 
abating.  If  the  croup  continue  from  four  to  six  days,  the  pseudo-mem- 
brane begins  to  soften  from  commencing  decomposition  and  to  disinte- 
grate. The  minute  fibres  which  attach  it  to  the  membrane  give  way,  and 
in  favorable  cases  by  the  effort  of  coughing  or  vomiting  it  is  thrown  off. 
Separation  is  aided  by  the  muco-pus  which  collects  underneath. 

Symptoms — Whenever  croup  is  one  of  the  local  manifestations  of 
diphtheria,  such  general  or  constitutional  symptoms  are  present  as  pertain 
to  this  blood  disease,  such  as  febrile  movement,  anorexia,  thirst,  and  pro- 
gressive loss  of  flesh  and  strength.    The  temperature  in  the  commence- 


324         Smith,  Membranous,  Diphtheritic,  and  True  Croup.  [April 


ment  in  croup  from  this  cause  is  usually  higher  than  at  an  advanced 
period,  unless  some  complication  occur,  as  pneumonia,  which  increases 
the  heat  of  the  system.  The  temperature  is  not,  however,  in  the  begin- 
ning, ordinarily  above  103°  or  104°,  and,  as  the  croup  continues,  and  the 
systemic  blood-poisoning  becomes  more  marked,  the  temperature  usually 
falls,  so  that,  even  in  the  gravest  cases,  it  is  often  at  or  below  100°.  Most 
patients  also  have  those  inflammations  which  commonly  attend  diphtheria, 
i.  e.,  pharyngitis  and  more  or  less  coryza,  but  they  are  relatively  unim- 
portant in  comparison  with  the  croup,  for,  unlike  the  croup,  they  do  not 
in  themselves  involve  immediate  danger  to  life. 

Croup  commonly  begins  gradually  and  insidiously,  revealed  at  first  to 
the  physician  by  hoarseness  or  huskiness  of  the  voice,  and  a  hoarse  or 
harsh  cough.  Both  voice  and  cough  are  feeble,  lacking  the  fulness  and 
sonorousness  present  in  spasmodic  laryngitis.  In  grave  cases,  approaching 
a  fatal  termination,  the  voice  becomes  more  and  more  indistinct,  and 
finally  is  suppressed.  The  cough,  also,  which  in  the  beginning  of  the 
croup  was  strong  and  expulsive,  becomes  feeble  and  ineffectual,  and  less 
frequent  as  the  fatal  result  draws  near. 

The  amount  of  sputum  varies  considerably  in  different  cases.  If  the 
inflammation  extend  no  further  downward  than  the  trachea  it  is  scanty, 
but  if  there  be  coexisting  bronchitis,  it  is  more  abundant,  consisting  of 
muco-pus  with  occasional  flakes  of  pseudo-membrane.  By  vomiting  a 
larger  quantity  is  expelled  than  by  the  cough.  Occasionally  masses  of 
pseudo-membrane  of  considerable  size  are  expectorated,  even  moulds  of 
some  part  of  the  respiratory  passage,  always  with  great  tomporary  relief 
to  the  patient.  A  pseudo-membrane  of  considerable  thickness  and  extent 
obstructs  the  expectoration  of  muco-pus,  which,  collecting  in  the  lower 
part  of  the  trachea  and  in  the  bronchial  tubes,  greatly  increases  the  dys- 
pnoea. The  respiration  is  somewhat  more  frequent  than  in  health,  but  it 
is  not  notably  increased  except  when  bronchitis  or  broncho-pneumonia 
is  present.  At  an  advanced  stage,  when  stupor  supervenes  from  non- 
oxygenation  of  the  blood,  the  respiration  may  be  slower  than  in  health. 

Croup  in  its  commencement  and  in  the  active  period  of  diphtheria 
without  treatment  almost  never  remains  stationary  or  abates.  Little  by 
little  or  often  quite  rapidly,  the  laryngeal  stenosis  increases,  and  soon  the 
patient  begins  to  experience  the  want  of  air.  He  becomes  restless,  has 
an  anxious  expression  of  the  face,  seeks  change  of  position,  reaching  out 
his  arms  to  the  nurse  or  mother  to  obtain  relief.  In  some  patients  only  a 
few  hours  elapse  and  in  others  a  day  or  more  of  gradual  increase  in  the 
obstruction,  when  it  becomes  evident  that  death  must  soon  occur  unless 
relief  be  afforded.  In  this  stage  the  post-clavicular,  infra-clavicular, 
supra-sternal,  and  infra-mammary  regions  are  depressed  during  inspir- 
ation, and  the  larynx  is  drawn  with  each  inspiratory  act  towards  the 
sternum.    While  there  is  constant  suffering,  there  are  also  occasionally 


1885.]     Smith,  Membranous,  Diphtheritic,  and  True  Croup.  325 


most  distressing  attacks  of  dyspnoea  attended  by  an  increase  in  the  lividity 
of  the  features  and  extremities  which  now  have  an  habitual  dusky  pallor. 
Sometimes  these  attacks  are  perhaps  due  to  the  doubling  of  a  detached 
end  of  the  pseudo-membrane  on  itself,  or  perhaps  to  a  movement  of  the 
muco-pus  by  which  bronchial  tubes  are  occluded.  With  the  ear  applied 
over  the  larynx  or  upper  part  of  the  sternum,  a  loud  rhonchus  is  heard  both 
on  inspiration  and  expiration,  produced  by  the  passage  of  the  air  over  the 
obstruction,  and  obscuring  to  a  great  extent  the  other  sounds.  Moist 
bronchial  rales  are  also  common. 

Those  who  recover  from  membranous  croup  without  tracheotomy,  and 
by  the  use  of  inhalations,  and  thus  far  they  constitute  only  a  small 
minority,  usually  improve  gradually,  the  obstruction  diminishing  by 
softening  and  detaching  of  portions  of  the  pseudo-membrane,  the  cough 
becoming  looser  and  the  voice  less  hoarse.  After  the  detachment  of  the 
pseudo-membrane,  several  days  elapse  before  the  thickening  and  infil- 
tration of  the  mucous  membrane  disappear  and  the  epithelial  cells  are 
restored. 

Diagnosis  Catarrhal  laryngitis  with  a  usual  amount  of  thickening 

and  infiltration  of  the  mucous  membrane  and  the  underlying  connective 
tissue,  so  as  to  produce  stenosis  and  obstruct  respiration,  may  be  mistaken 
for  pseudo-membranous  inflammation.  In  the  !N.  Y.  Foundling  Asylum, 
two  children  have  at  different  times  died  with  the  symptoms  of  membra- 
nous laryngitis,  and  the  obstruction  was  found  to  be  due  entirely  to  the 
thickening  and  infiltration  of  the  mucous  and  submucous  tissues  of  the 
larynx  by  newly-formed  corpuscular  elements.  Of  course,  death  from 
catarrhal  laryngitis  is  rare,  but  that  this  disease  may  produce  such  an 
amount  of  laryngeal  stenosis  as  to  cause  even  fatal  dyspnoea,  like  that 
from  the  presence  of  pseudo-membrane,  these  two  cases  show.  In  most 
instances,  the  diagnosis  of  membranous  laryngitis  from  catarrhal  laryngitis 
is  easy,  by  the  presence  of  patches  of  pseudo-membrane  on  the  fauces,  or  by 
the  history  of  the  case,  which  evidently  points  to  diphtheria  as  the  cause.  I 
have  elsewhere  alluded  to  a  child  in  my  practice  who  died  with  the  symp- 
toms of  acute  laryngeal  stenosis,  without  any  pseudo-membrane  upon  visible 
parts,  and  with  only  a  moderate  pharyngitis.  This  case,  which  might  have 
passed  as  one  of  catarrhal  laryngitis,  accompanied  by  an  unusual  amount  of 
cellular  and  serous  infiltration,  as  there  was  no  known  diphtheria  in  the 
vicinity,  was  really  due  to  diphtheria,  and  was  a  local  manifestation  of 
that  disease,  for  immediately  after  the  death  of  the  patient  the  two  nurses 
had  unequivocal  symptoms  of  diphtheria.  The  difficulty  in  using  the 
laryngoscope  in  young  children  is  such,  when  their  fauces  are  swollen, 
that  it  has  not  heretofore  aided  much  in  the  differential  diagnosis  of  the 
various  forms  of  acute  laryngeal  stenosis  in  young  children,  at  least  when 
employed  by  the  general  practitioner. 


326 


Smith,  Membranous,  Diphtheritic,  and  True  Croup.  [April* 


Prognosis. — The  mortality  from  croup  obviously  depends  to  a  great 
extent  on  the  prevalence  and  the  type  of  diphtheria.  .  From  what  has  been 
stated  above,  it  follows  that  croup  is  more  frequent  and  more  fatal  in  a 
grave  form  of  diphtheria  than  in  mild  epidemics  with  a  less  degree  of 
blood-poisoning.  In  New  York  City,  during  the  fifteen  years  ending  with 
1878,  the  percentage  of  recoveries  was  very  small,  both  under  medicinal 
treatment  and  tracheotomy.  During  this  long  period,  surgeons,  not  saving 
more  than  three  to  five  per  cent,  of  their  cases  by  tracheotomy,  performed 
this  operation  reluctantly.  But  since  1878  the  percentage  of  recoveries 
after  tracheotomy  has  been  much  greater.  The  mortality  from  croup  is 
greater  the  younger  the  patient ;  for  the  younger  the  child,  the  less  the  dia- 
meter of  the  air-passages,  and  the  more  quickly  laryngeal  stenosis  results. 
The  younger  the  child,  also,  the  more  difficult  is  the  use  of  the  proper  reme- 
dies, and  the  less  the  time  for  their  use  before  fatal  dyspnoea  occurs.  We 
have  already  said  that  croup  appearing  in  the  declining  stage  of  diphtheria 
is  less  severe  and  more  easily  controlled  or  cured  than  when  it  occurs  in 
the  commencement  of  diphtheria.  Much  depends,  also,  upon  whether  the 
physician  is  summoned  at  the  very  beginning  of  the  croup,  and  appropriate 
remedies  are  early  and  persistently  employed.  In  many  instances  the 
friends  do  not  take  alarm,  and  the  physician  is  not  summoned  till  the 
disease  is  well  under  headway,  and  there  is  not  the  requisite  time  for  the 
action  of  inhalations.  Obviously,  also,  croup,  beyond  all  other  diseases, 
requires  faithful  and  intelligent  nurses,  for  without  the  co-operation  of  such 
nurses  night  and  day,  in  the  care  of  the  patient,  the  most  judicious  mea- 
sures are  often  rendered  inefficient. 

Exact  statistics  are  lacking  to  show  what  proportion  of  cases  of  croup 
recover  by  strictly  medicinal  treatment.  If  we  regard  as  incipient  croup 
those  cases  in  which  the  voice  becomes  hoarse  or  harsh,  but  no  dyspncea 
occurs,  and  the  lungs  are  fully  and  normally  inflated,  a  considerable 
number,  I  think,  more  than  fifty  per  cent,  in  my  practice  recover.  There 
may  be  in  these  cases  a  catarrhal  laryngitis,  or  there  may  be  a  thin  .film 
of  pseudo-membrane  upon  the  laryngeal  surface,  not  sufficient  to  embarrass 
respiration.  Slight  laryngitis,  therefore,  occurring  in  the  course  of  diph- 
theria, unaccompanied  by  any  increase  in  temperature,  or  change  in  the 
freedom  or  rhythm  of  respiration,  and  whose  only  symptom  is  a  huskiness 
of  voice,  if  treated  early  and  properly  by  inhalations,  passes  off  in  a  few 
days  in  a  large  proportion  of  cases.  It  possesses  little  importance  except 
that  it  might  be  the  initial  stage  of  croup  if  neglected.  It  is  obviously 
improper  to  consider  this  trivial  form  of  laryngitis  as  membranous  croup, 
although  by  neglect  it  might  become  such.  In  the  statistics  of  croup, 
those  cases  only  should  be  included  in  which  the  symptoms  are  so  pro- 
nounced that  it  is  evident  that  more  or  less  laryngeal  stenosis  is  present, 
although  there  may  as  yet  be  no  marked  dyspnoea. 


1885.]     Smith,  Membranous,  Diphtheritic,  and  True  Croup.  327 


In  determining  the  percentage  of  recoveries  in  croup,  it  is  proper  to 
arrange  cases  in  two  groups:  1st,  cases  which  have  received  only  medicinal 
treatment ;  2d,  cases  in  which  tracheotomy  has  been  performed.  Having 
been  in  almost  continuous  practice,  since  diphtheria  began  in  New  York, 
in  a  section  of  the  city  where  this  disease  has  always  been  prevalent,  and 
having  witnessed  all  kinds  of  treatment — that  by  emetics,  by  depletion, 
by  stimulation,  by  inhalation  and  insufflation — it  is  my  opinion  that  not 
more  than  one  in  eight  has  recovered  by  medicinal  treatment  in  this  long 
period,  of  cases  of  croup,  which  began  in  the  first  week  of  diphtheria,  and 
in  which  the  symptoms  were  so  pronounced  as  to  indicate  more  or  less 
laryngeal  stenosis.  The  exudation  in  the  first  week  of  diphtheria,  or  in 
its  active  period,  occurs  so  rapidly,  and  in  such  large  quantity,  that  no  one 
of  the  medicinal  agents  or  modes  of  treatment,  which  physicians  commonly 
prescribe,  is  sufficiently  prompt  in  its  action  to  prevent  the  formation  of 
the  pseudo-membrane  to  an  extent  that  soon  endangers  life.  I  allude  to 
what  has  hitherto  been  the  result. 

Perhaps  we  may  yet  discover  a  mode  of  treatment  that  more  effectually 
controls  the  formation  of  pseudo-membrane. 

Croup  occurring  in  the  second  or  third  week  of  diphtheria,  since  it  is 
attended  by  less  abundant  and  less  rapid  exudation  than  when  it  occurs 
during  the  acute  stage,  can  be  more  successfully  treated  under  the  perse- 
vering use  of  solvent  inhalations,  and,  according  to  my  observations,  a 
larger  proportion  than  one  in  eight,  perhaps  one  in  three,  recovers  by 
the  early  and  continuous  or  almost  continuous  use  of  inhalations. 

Still  the  mortality  is  so  large,  and  the  suffering  so  great  in  croup,  at 
wrhatever  stage  of  diphtheria  it  occurs,  that  we  cannot  rely  on  the  slow 
action  of  medicines  or  inhalations,  and  surgical  treatment  is  in  most 
instances  required  to  diminish  the  suffering,  and  afford  the  best  chances 
for  saving  life.  Tubing  the  larynx,  to  which  we  will  allude  hereafter,  has 
been  so  seldom  performed,  and  the  statistics  of  it  are  so  meagre,  that  we 
are  unable  to  state  what  proportion  of  patients  may  be  saved  by  it.  I 
have  twice  observed  in  the  New  York  Foundling  Asylum  prompt  relief 
from  tubage,  when  the  dyspnosa  was  so  great  as  to  threaten  immediate 
death.  In  one  of  the  two  patients  the  relief  was  temporary,  and  in  the 
other  permanent.  If  the  obstruction  was  confined  to  the  larynx  or  larynx 
and  upper  part  of  the  trachea,  tubage  would,  I  think,  come  into  general 
use  as  a  substitute  for  tracheotomy,  but,  unfortunately,  it  fails  to  give 
relief  and  save  life  in  those  many  cases  in  which  the  obstruction  extends 
throughout  the  trachea  and  into  the  bronchi.  The  statistics  of  trache- 
otomy, on  the  other  hand,  are  abundant,  and  we  are  enabled  therefore  to 
determine  to  what  extent  it  can  rescue  the  victims  of  this  disease  from 
impending  death.  The  American  Journal  of  Obstetrics  for  May,  1868, 
gives  the  results  of  tracheotomy  performed  by  Drs.  Jacobi,  Krackowizer, 
and  Yoss  as  follows : — 


328 


Smith,  Membranous,  Diphtheritic,  and  True  Croup.  [April 


Cases. 

Recove- 

Deaths. 

Per  cent,  of 

recoveries. 

Jacobi,  Krackowizer,  and.  Voss      •       .  . 

166 

39 

127 

J.  H.  Ripley,  N.Y.  Med.  Record,  1880 

56 

16 

Parisian  Children's  Hosp.,  1851-1875  (Tenne) 

4663 

24 

"Rpthqnipn  in  Rprlin    1861-1872  f  Ra  rt.pl 

330 

103 

31.2 

Berliner  Chirurg.  Klinik,  1870-1876  (Krbnlein) 

504 

147 

29 

St.  Annenspital  TVien  (Monti)      .      .  . 

210 

33 

Table  of  Monti  from  various  sourc.es 

2608 

25 

Hofroohl's  statistics  ..... 

3760 

27 

Kiister's  statistics  ...... 

1556 

32 

C.  Hospital,  Trousseau,  Paris,  during  1883 

(per  Dr.  L.  Enfance)  ..... 

359 

115 

244 

32 

Clinic  of  the  Zurich  Kantonspitals,  under  Rose 

and  F.  Krbnlein,  1868,  Mar.  1882  (11  under 

2  years  1  of  8  months) 

938 

92 

39 

Deutsche  Zeitschrift  fur  Chirurg.,  1882,  Bd. 

xvii.  (H.  Lindner)  ..... 

101 

37%" 

Statistik  der  Tracheotomie  per  Croup,  Deutsche 

Chirurger  Lieferung,  37  Stuttgard,  1880,  by 

Kiihn    .       .  . 

277 

125 

152 

Hopital  des  Enfants  Malad.,  Paris,  1850-1857 

389 

86 

22 

HOpital  des  Enfants  Malad.,  Paris,  1860-1867 

813 

208 

Trousseau,  according  to  Kiihn 

466 

126 

_ 

25 

Guersant  (Sedillot),  Med.  Oper.,  ii.  page  480 

171 

36 

— 

21 

Barthef,  Hospital  St.  Eugenie,  1855-1868  . 

573 

160 



28 

Cases  in  the  Parisian  Hospitals  and  in  the 

Provinces,  Fascher  et  Bricheteau 

1011 



25 

Roser  (Lissard),  C.  C.,  1854-1861  .  . 

42 

19 



45.4 

Operations. 

Recove- 

Per cent,  of 

ries. 

recoveries. 

Uhde,  Archiv  f.  Klin.  Chir.  1869,  1820-1869 

81 

21 

25 

Max  Muller  (Langenb.  Arch.  f.  Klin.  Chir.  vii.) 

45 

15 

33 

Bardenheuer  (Coiner  Biirgerhospitals,  1875-1876)  . 

129 

46 

35.6 

Krankenhause  Bethanien,  1873,  and  following  (H. 

375 

119 

31 .75 

Billroth,  Chirurg.  Klinik  Wien.,  1871-1876 

18 

1 

Reisz,  Bronchotomiens  Indicat.,  1858 

17 

5 

Wansher  (Copenhagener  Kommuni  Hospitals,  Sept. 

1863,  Dec.  1876)  

400 

170 

42.5 

The  result  of  tracheotomy  in  infants 

is  mu 

ch  less  favorable  than  in 

older  children.  Dr.  Gustav  Chagin  has  published  in  the  Archiv  fiir 
Kinderheilkunde,  Bd.  iv.,  the  statistics  of  cases  in  infancy.  These  cases, 
977,  occurred  since  1874;  and  of  this  number,  832,  or  85  per  cent.,  died. 
In  the  Copenhagener  Kommuni  Hospital,  in  which,  as  stated  above,  there 
was  the  remarkably  good  general  result  of  170  recoveries  in  400  tracheo- 
tomies, only  5  per  cent,  recovered  of  children  under  one  year;  of  76  ope- 
rated on  between  the  ages  of  one  and  two  years,  22  recovered,  or  >29  per 
cent.;  while  of  296  operated  on  between  the  ages  of  two  and  ten  years, 
146  recovered,  or  49.3  per  cent.  In  the  Krankenhause  Bethanien,  the 
results  of  tracheotomy  from  the  beginning  of  1861  to  the  close  of  1876, 
tabulated  according  to  the  age,  were  as  follows  (H.  Settegast)  : — 


1885.]     Smith,  Membranous,  Diphtheritic,  and  True  Croup.  329 


Age.  Tracheotomies.  Eecovered.  Percent. 

2  to  3  years   93  22  23.65 

3  "   4  "   165  47  28.45 

4  "   5  "                                               .       .  175  54  30.85 

5  «   6  "   107  39  35.45 

6  "  7  "   90  34  37.77 

7  "  8  "   59  17  38.86 

8  "  9  "   24  11  45.83 

9  "  10  "    .    15  6  40.00 


These  statistics  show  that  the  older  the  patient  upon  whom  tracheotomy 
is  performed,  other  things  being  equal,  the  greater  the  percentage  of  reco- 
veries. Prof.  Abraham  Jacobi  has  probably  performed  tracheotomy  for 
croup  in  as  many  cases  as  any  other  physician  or  surgeon  in  this  country, 
not  fewer,  he  thinks,  than  400  times.  His  opinion  corresponds  with 
the  common  belief  that,  during  the  last  five  years,  the  percentage  of 
recoveries  after  tracheotomy,  in  New  York  City,  has  been  much  larger 
than  previously,  and  the  operation  is  performed  more  frequently  by  the 
attending  physician  than  formerly.  The  result  of  tracheotomy  during  a 
long  series  of  years,  ending  with  1878  or  1879,  was  so  unfavorable,  on 
account  of  the  type  of  the  disease,  that  Dr.  Jacobi  thinks,  in  the  aggregate 
of  his  cases  of  tracheotomy  since  1858,  only  about  12  per  cent,  recovered. 

Although  at  present  in  this  city  the  percentage  of  recoveries  after 
tracheotomy  is  much  larger  than  formerly,  yet  the  statistics  of  some  of 
the  prominent  physicians  and  surgeons  show  nearly  as  large  a  proportion 
of  death  as  in  former  years,  probably  because  the  operation  has  been 
deferred  till  the  patients  were  nearly  moribund.  Thus,  one  surgeon 
records  only  4  recoveries  in  21  operations  during  the  last  three  or  four 
years,  and  a  physician  of  large  experience,  connected  with  one  of  the 
institutions  where  children  are  treated,  has  been  equally  unsuccessful  in 
his  tracheotomies,  but  he  has  operated  only  when  the  dyspnoea  was  ex- 
treme, and  death  momentarily  expected.  Earlier  operation  might  have 
given  better  results. 

The  statistics  of  recent  tracheotomies,  which  seem  to  me  to  indicate 
most  accurately  the  results  of  this  operation  when  skilfully  performed, 
and  not  at  too  late  a  stage  in  the  type  of  diphtheria  now  prevailing  in  this 
city,  I  have  obtained  from  Drs.  J.  H.  Ripley  and  Fred.  Lange.  The 
operations  embraced  in  their  statistics  were  performed  since  January  1, 
1879,  with  the  following  result  : — 

Tracheotomies.  Died.  Eecovered.        Per  cent,  of  recoveries. 

66    •  44  22  33^ 

These  surgeons  do  not  select  cases  for  the  operation,  but  they  operate 
on  nearly  every  patient  with  croup,  to  whom  they  are  summoned,  provided 
that  death  seems  inevitable  without  tracheotomy.  They  operate  even  if 
serious  complications  be  present,  as  nephritis  or  pneumonia,  or  the  blood 
be  profoundly  poisoned.    With  them  the  inducement  to  operate  is  suffi- 


330         Smith,  Membranous,  Diphtheritic,  and  True  Croup.  [April 


cient  if  tracheotomy  diminish  the  suffering,  or  increase  the  chances  of 
recovery  in  however  trifling  a  degree.  Inasmuch,  therefore,  as  they  do 
not  select  cases,  so  good  a  result  is  noteworthy. 

Some  physicians  in  this  city  make  greater  discrimination  in  cases,  and 
do  not  operate  if  the  condition  of  the  patient  be  such  that  death  will  in 
all  probability  occur  after  tracheotomy.  They  do  not,  therefore,  advise 
the  operation,  if  the  patient  have  profound  blood-poisoning  or  severe  local 
disease  elsewhere  than  in  the  air-passages.  Such  physicians  by  the  early 
performance  of  tracheotomy,  and  by  careful  attention  to  the  after-treat- 
ment, making  frequent  visits  and  supervising  the  details  of  the  manage- 
ment, furnish  more  favorable  statistics  of  the  operation  than  any  of  those 
published  above.  Thus,  Dr.  A.  R.  Robinson,  who  makes  such  discrimi- 
nation in  cases,  who  operates  early,  does  not  insert  the  canula  until  all 
loose  muco-pus  and  shreds  of  pseudo-membrane  are  expelled  by  the  cough 
from  the  trachea  and  bronchial  tubes,  and  who  supervises  by  frequent 
visits  the  after-management,  has  saved  since  1880  eleven  in  thirteen  con- 
secutive cases  of  undoubted  membranous  croup.  It  is  seen  from  the  above 
statistics  that  we  can  claim  for  tracheotomy  judiciously  performed,  and  at 
a  sufficiently  early  stage,  the  cure  of  one  in  every  three  patients  in  the 
average.  The  statistics  in  Boston  show  that  the  results  obtained  in  that 
city  in  hospital  practice  have  been  about  the  same  as  those  in  New 
York  and  in  European  cities.  In  an  interesting  paper  on  tracheotomy  in 
croup,  published  in  the  Medical  Neivs,  July  12,  1884,  the  writer  says: 
"Tracheotomy  for  this  disease  has  been  performed  one  hundred  and 
eighteen  times  at  the  Boston  City  Hospital  during  the  past  twenty  years. 
Thirty-nine,  or  one  in  three,  were  successful.  That  the  cases  were  not 
selected  is  shown  by  the  fact  that  three  patients  died  during  the  opera- 
tion from  shock  and  exhaustion,  not  from  hemorrhage  ;  thirty-four  died 
within  twenty-four  hours  ;  and  fifty-six,  or  more  than  one-half  of  the 
fatal  cases,  within  forty-eight  hours.    Four,  if  not  five,  of  the  successful 

cases  were  practically  moribund  at  the  time  of  the  operation  

The  ages  of  these  patients  ranged  from  nine  months  to  forty-one  years. 
The  youngest  to  recover  was  eleven  months ;  the  oldest  sixteen  years. 
Four  aged  two  years  and  five  aged  three  years  got  well.  Membrane  was 
visible  in  the  fauces  or  trachea  in  a  large  proportion  of  both  the  successful 
and  unsuccessful  cases.  Its  absence  was  noted  in  only  three  of  each  class. 
It  need  not  be  said  that  in  every  instance  there  was  present  severe,  con- 
stant, and  increasing  dyspnosa,  exhausting  the  strength  and  threatening 
suffocation." 

Preventive  Treatment  In  attending  a  case  of  diphtheria  the  phy- 
sician should  notice  at  each  visit  whether  the  patient  have  any  hoarse- 
ness or  other  signs  indicating  implication  of  the  larynx,  since,  if  the 
danger  be  recognized  at  its  inception,  it  may  perchance  be  averted.  Inef- 


1885.]     Smith,  Membranous,  Diphtheritic,  and  True  Croup.  331 


fectual  as  inhalations  may  be  for  fully  declared  croup,  we  have  seen  in 
speaking  of  the  prognosis  that  experience  fully  justifies  the  belief  that 
they  are  sufficient  in  a  large  proportion  of  cases  to  relieve  that  degree  of 
laryngitis  which  is  indicated  by  simple  hoarseness,  and  which  if  it  con- 
tinue might  eventuate  in  serious  obstructive  disease.  If  the  physician 
observe  such  symptoms,  he  should  immediately  recommend  that  the  air  in 
the  apartment  be  kept  moist  by  the  croup  kettle  or  pans  of  hot  water  over 
the  fire,  into  each  of  which  a  lump  of  lime  is  placed.  I  frequently  sur- 
round the  bed  with  a  tent  made  with  a  clothes-horse,  over  which  blankets 
are  thrown,  and  place  the  croup  kettle  underneath.  Frequently  stirring 
the  water  in  the  kettle  adds  to  its  efficiency.  I  prefer,  however,  in  most 
instances,  to  employ  the  steam  atomizer  either  with  or  without  the  croup 
kettle.  It  should  be  so  constructed  that  it  throws  a  heavy  spray  of  rather 
turbid  lime-water,  and  should  be  almost  continuously  used  as  long  as  the 
premonitory  symptoms  of  croup  continue.  It  obviates  the  necessity  of 
heating  the  apartment,  which  in  hot  weather  is  very  uncomfortable. 

It  is  proper  in  this  connection  to  consider  which  is  the  most  efficient 
and  the  best  agent  for  inhalation  in  croup.  Have  we  an  agent  that  can 
be  safely  used,  which  will  prevent,  when  inhaled,  the  formation  of  the 
pseudo-membrane,  or  which  will  dissolve  it  when  it  has  already  formed  ? 
The  agents  which  have  been  most  employed  for  this  purpose  are  lime- 
water,  lactic  acid,  pepsin,  and  bromine. 

In  selecting  the  one  that  is  safest  and  most  efficient,  the  important  fact 
should  be  borne  in  mind  that  anything  which  irritates,  so  as  to  increase  the 
inflammation  of  the  mucous  surface,  is  injurious.  Whatever  intensifies 
the  inflammation,  evidently  augments  the  thickening  and  infiltration  of 
the  mucous  membrane,  and  increases  the  area  as  well  as  thickness  of  the 
pseudo-membrane.  It  is  therefore  harmful  instead  of  beneficial.  In  my 
opinion  the  teachings  of  Bretonneau  and  Trousseau  did  immense  harm  in 
the  fact  that  they  brought  into  use  agents  far  too  irritating  to  the  sensi- 
tive mucous  surface.  Since  the  pressing  danger  in  croup  arises  from  the 
obstruction  produced  by  the  pseudo-membrane,  and  by  the  thickening  and 
infiltration  of  the  mucous  membrane  underneath,  that  agent  is  indicated, 
if  it  can  be  found,  which  loosens  and  dissolves  the  pseudo-membrane,  and 
at  the  same  time  tends  to  diminish  or  at  least  does  not  increase  the  inflam- 
mation of  the  underlying  tissues  by  its  irritating  action.  Alkalies  exert 
a  solvent  action  on  fibrin  and  mucin,  and  as  the  pseudo-membrane  con- 
sists of  the  exudate  from  the  blood  largely  fibrinous,  and  of  epithelium 
and  connective  tissue  which  have  undergone  degeneration  into  a  substance 
resembling  fibrin  (Wagner)  or  perhaps  mucin  (Cornil  and  Ranvier),  their 
employment  seems  to  rest  on  a  sound  therapeutic  basis.  Lime-water 
slightly  turbid,  but  not  so  turbid  as  to  clog  the  point  of  the  steam  ato- 
mizer, and  containing  about  one  and  a  half  per  cent,  of  liquor  potassaa,  is 


332 


Smith,  Membranous,  Diphtheritic,  and  True  Croup.  [April 


probably  as  efficient  and  useful  a  solvent  as  any  of  the  alkaline  mixtures. 
One  and  a  half  per  cent,  liquor  potassae  becomes  about  one  per  cent,  when 
mixed  with  steam  from  the  boiler. 

By  the  persistent  and  timely  use  of  such  inhalations  as  soon  as  hoarse- 
ness appears,  croup  can,  in  my  own  opinion,  be  often  prevented.  But  we 
all  know  how  often,  notwithstanding  our  best  endeavors,  croup  occurring 
in  the  first  week  of  diphtheria  grows  hourly  worse.  In  these  acute  and 
rapid  cases  inhalations  of  the  best  agents,  which  physicians  have  hitherto 
used,  act  too  slowly  to  prevent  the  growth  of  the  pseudo-membrane,  and 
in  a  few  hours  it  becomes  painfully  evident  that  something  more  must  be 
done  or  the  life  of  the  child  is  lost.  In  those  many  cases  in  which  diph- 
theria is  ushered  in  with  croupous  symptoms,  and  in  which,  within  a  few 
hours,  laryngeal  stenosis  begins  to  occur,  the  experienced  physician  sees 
at  a  glance,  often  at  his  first  visit,  that  inhalations,  however  faithfully  em- 
ployed, will  be  inadequate,  and  thai  suffocation,  the  most  painful  of  all 
modes  of  death,  will  be  inevitable,  unless  other  and  energetic  measures 
are  used. 

On  the  other  hand,  in  the  milder  forms  of  croup,  in  which  the  exuda- 
tion has  but  moderate  thickness  and  forms  slowly,  inhalations  are  of  the 
greatest  service,  and,  aided  by  internal  remedies,  they  not  infrequently 
arrest  the  disease  and  save  life.  The  following  was  such  a  case  :  M.  J., 
a  girl  of  two  years  and  five  months,  took  diphtheria  on  January  G,  1884. 
I  first  saw  her  on  the  9th,  when  a  considerable  amount  of  pseudo-mem- 
brane covered  the  fauces.  The  temperature  was  but  moderately  elevated, 
and  a  slight  discharge  occurred  from  the  nostrils.  Under  the  usual  treat- 
ment the  pharyngitis  abated,  and  she  seemed  to  be  convalescing  until 
January  14th,  when  her  respiration  began  to  be  noisy  and  embarrassed. 
On  inspecting  the  fauces  a  pseudo-membrane  was  seen  upon  the  aperture 
of  the  glottis,  apparently  dipping  down  into  it.  The  steam  atomizer 
was  employed  almost  constantly,  throwing  a  spray  of  lime-water  with 
about  one  per  cent,  of  liquor  potassse.  Each  inspiration  was  accom- 
panied by  marked  depression  of  the  post-clavicular,  epigastric,  and  infra- 
mammary  regions,  and  the  respiration  was  noisy  and  embarrassed  till  the 
17th,  when  it  began  to  improve,  and  the  patient  was  soon  out  of  danger. 
It  will  be  observed  that  the  croup  commenced  in  the  second  week  or  in  the 
declining  stage  of  diphtheria.  Had  it  been  earlier,  when  the  inflamma- 
tion was  more  active,  and  the  exudation  more  rapid,  in  all  probability  the 
patient  would  have  perished  unless  saved  by  tracheotomy.  The  slowness 
of  the  exudative  process  afforded  time  for  the  action  of  solvent  inhalations. 
Nearly  at  the  same  time  that  this  case  occurred,  a  patient  in  my  practice, 
who  had  recovered  from  croup  by  tracheotomy,  was  seized  with  dyspnoea 
a  month  after  the  operation,  when  the  opening  had  healed,  and  a  flapping, 
r-ound  could  be  distinctly  heard,  produced  probably  by  a  pseudo-membrane, 
which  was  partially  detached.    This  obstruction,  which  for  a  time  apt>a-^ 


1885.]     S  mith,  Membranous,  Diphtheritic,  and  True  Croup.  333 


rently  involved  great  danger  from  the  dyspnoea  which  it  caused,  was  re- 
moved by  the  third  day  under  alkaline  inhalations.  In  such  cases,  in 
which  the  inflammation  is  mild  and  the  exudation  at  a  stand-still,  or  slow, 
the  benefit  from  inhalations  is  most  apparent.  I  am  confident  that  one 
good  result  from  alkaline  inhalations  is  not  fully  appreciated  by  the  pro- 
fession ;  I  refer  to  the  fact  that  they  render  the  muco-pus,  which  collects  in 
large  quantity  in  the  bronchial  tubes,  and  is  expectorated  with  difficulty, 
on  account  of  its  viscidity,  and  the  obstacle  above  it,  thinner  and  more 
easily  expelled. 

Now  that  diphtheria  has  become  so  prevalent  in  this  country,  and  so 
many  children  perish  of  the  croup  which  it  produces,  it  is  to  be  hoped  that 
some  more  efficient,  and  at  the  same  time  unirritating  substance  may  be 
discovered  for  inhalation  than  those  at  present  in  use. 

Since  my  attention  has  been  called  to  the  fact,  by  Dr.  Yan  Syckel,  of 
New  York,  that  trypsine,  one  of  the  digestive  ferments  secreted  by  the 
pancreas,  is  a  rapid  solvent  of  fibrine,  he  having  observed  its  action  in  the 
laboratory  of  Prof.  Kiihne,  of  Heidelberg,  I  have  employed  this  agent 
in  the  usual  form  of  diphtheria  in  several  instances  with  such  result  as  to 
encourage  the  hope  that  the  solvent  which  we  have  so  long  needed  has 
been  found.  I  have  never  seen  pseudo-membranes  disappear  from  the 
fauces  more  rapidly  than  in  cases  in  which  the  following  mixture  was 
applied,  every  half  hour,  with  a  large  camel's-hair  pencil,  whether  the 
good  effect  was  due  to  the  trypsine  contained  in  the  extract,  or  to  the 
alkali,  or  to  the  combination  of  the  two : — 

Extracti  pancreatis  (Fairchild's),  3j  ; 
Sodii  bicarbonat.  sjiij.  M. 
Add  one  teaspoonful  of  this  to  six  teaspoonfuls  of  water. 

Thus  recently,  in  a  child  of  about  five  years,  a  thick  pseudo-membrane 
over  each  tonsil  had  disappeared  by  the  third  day,  without  apparently 
any  irritating  effect  from  the  application.  Mr.  Fairchild  has  recently 
prepared  trypsine  in  a  liquid  form,  in  order  that  its  efficacy  can  be  more 
readily  and  conveniently  tested  as  a  solvent  for  the  membranes  in  croup ; 
and  Dr.  H.  D.  Chapin  informs  me  that  this  liquid  employed  in  spray 
quickly  dissolved  the  pseudo-membrane  in  situ  upon  the  larynx  removed 
from  an  infant  that  perished  from  this  disease.  Additional  clinical  ob- 
servations will  soon  determine  the  value  of  trypsine  as  a  solvent,  and 
whether,  if  it  be  a  good  solvent,  it  can  be  utilized  as  a  spray.  That  it 
requires  an  alkaline  medium  for  its  activity,  renders  it  compatible  with 
alkaline  inhalations. 

Internal  Treatment — Calomel, — This  was  long  regarded  as  the  most 
important  internal  remedy  for  membranous  croup,  as  well  as  for  diphthe- 
ritic exudations  elsewhere  than  in  the  larynx.  In  the  belief  that  it  had 
a  tendency  to  prevent  the  formation  of  pseudo-membranes,  and  aided  in 
detaching  and  removing  those  already  formed,  it  was  in  common  use  until 
No.  CLXXYIII  April,  1885.  22 


334         Smith,  Membranous,  Diphtheritic,  and  True  Croup.  [April 


about  twenty-five  years  ago.  It  was  sometimes  prescribed  for  croup  in 
large  doses,  but  more  frequently  in  doses  of  one-half,  one,  or  one  and  a 
half  grains,  repeated  every  second  or  third  hour,  and  often  in  combination 
with  an  opiate,  as  Dover's  powder.  However  useful  a  remedy  it  may  be 
when  judiciously  employed  in  croup,  as  well  as  in  certain  other  diseases, 
it  fell  into  disuse  on  account  of  its  ill-advised  employment  in  diseases 
which  did  not  require  it,  its  employment  often  to  the  extent  of  producing 
unpleasant  and  even  dangerous  symptoms.  When  diphtheria  was  estab- 
lished in  this  country,  calomel  was  in  a  few  years  discarded  by  most  physi- 
cians as  a  remedy  for  croup,  on  account  of  the  growing  belief  that  nearly 
all  cases  of  this  disease  were  local  manifestations  of  diphtheria,  and  re- 
quired less  depressing  and  more  sustaining  measures  than  mercury.  More- 
over, it  was  easy  to  point  out  cases  in  the  writings  of  such  masters  of  the 
profession  as  Bretonneau  and  Trousseau,  in  which  calomel  was  improperly 
employed,  doing  harm  by  causing  not  only  severe  salivation,  but  also 
gangrene.  Nevertheless  cases  occurred  in  those  days  which  seemed  to 
show  tb&t  this  agent  properly  employed  is  a  potent  and  useful  remedy  for 
croup.  One  in  the  Astor  House  of  New  York  attracted  much  attention. 
A  child  of  about  two  years,  stopping  at  this  hotel,  had  pseudo-membranous 
laryngitis,  with  constant  and  increasing  dyspnoea.  Prominent  physicians 
summoned  to  him  expressed  the  opinion  that  he  could  not  live,  when, 
through  the  advice  of  a  physician  from  an  inland  city  who  was  tempo- 
rarily sojourning  in  the  hotel,  twenty  grains  of  calomel  were  placed  on 
his  tongue.  From  this  time  the  dyspnoea  began  to  abate,  and  the  patient 
recovered. 

The  medical  journals  from  time  to  time  contain  reports  of  cases  of  croup 
in  which  calomel  has  apparently  been  beneficial.  In  the  Med.  Record, 
July  12,  1884,  Dr.  J.  P.  Klingensmith,  of  Blairsville,  Pennsylvania, 
states  that  physicians  in  his  locality  prescribe  calomel  in  large  doses  for 
croup,  and  with  greater  success  than  that  achieved  by  other  modes  of 
treatment,  and  he  relates  three  cases,  showing  the  result  in  his  own 
practice  : — 

Case. — A  child  aged  28  months  took  twenty  grains  of  calomel  placed  on  the 
tongue  in  the  commencement  of  croup,  and  afterwards  ten  grains  every  hour  till 
the  third  day  when  720  grains  had  been  taken.  It  was  now  discontinued,  and 
on  the  sixth  day  the  pseudo-membrane  had  disappeared.  Recovery  was  rapid, 
and  without  any  untoward  symptoms. 

Case. — The  second  patient,  aged  three  and  a  half  years,  had  been  sick  forty- 
eight  hours,  with  a  temperature  of  102°  V.  He  had  a  croupy  cough,  and  a 
pseudo-membranous  exudation.  Twenty  grains  of  calomel  were  administered 
and  afterwards  ten  grains  every  hour  for  fifteen  hours,  so  that  one  hundred  and 
seventy  grains  were  administered.  The  child,  which  had  previously  been  restless, 
fell  into  a  quiet  natural  sleep.  The  calomel  was  discontinued,  and  a  mixture  of 
potassium  chlorate  and  ammonium  chloride  given  in  its  place.  On  the  fifth  day 
convalescence  was  fully  established,  without  any  unfavorable  symptoms. 

Case. — The  third  patient,  a  girl  of  four  years,  had  been  sick  twenty-four 
hoars,  with  "high  temperature,  painful  croupy  cough,  labored  respiration,  dry 
skin,  flushed  face,  and  some  diphtheritic"  exudation.    Twenty  grains  of  calomel 


1885.]     Smith,  Membranous,  Diphtheritic,  and  True  Croup.  335 


were  administered  and  followed  by  hourly  ten  grain  doses,  till  twelve  doses  were 
given.  No  other  remedy  was  employed,  and  in  three  or  four  days  the  patient 
recovered. 

These  appear  to  have  been  genuine  cases,  and  that  they  recovered 
tends  to  confirm  the  belief  that  calomel  does  exert  a  beneficial  action  on 
pseudo-membranous  inflammations,  either  diminishing  the  exudation,  or 
promoting  the  liquefaction  and  detachment  of  the  pseudo-membrane. 

A  mode  of  treatment  commonly  accepted  and  practised  by  the  profes- 
sion through  a  long  series  of  years  usually  does  some  good,  in  at  least  a 
certain  proportion  of  cases,  even  if  it  be  abused,  else  it  would  not  have 
been  likely  to  gain  general  acceptance.  We  know  how  quickly  calomel 
cures  the  mucous  patches  of  syphilis,  even  when  they  are  of  large  size. 
These  are  produced  by  inflammatory  changes  in  the  tegumentary  system, 
and  they  consist  largely  of  epithelial  or  epidermic  cells.  They,  therefore, 
contain  elements  similar  to  the  pseudo-membrane  in  croup,  but  without  the 
fibrin.  We  know  also  how  readily  fibrinous  opacities  on  the  cornea  yield 
to  calomel  dusted  on  them.  We  may  admit  that  calomel  probably  exerts 
a  salutary  action  either  on  the  exudative  process  or  the  pseudo-membrane, 
without  being  able  to  state  precisely  how  it  acts.  Bouchut  says  of  calomel 
in  his  article  on  croup  :  "This  medicine  promotes  the  expectoration  and 
the  rejection  of  the  false  membrane. "  Trousseau  believed  that  the  bene- 
ficial effects  of  the  mercurial  preparations  were  due  mainly  to  their  local 
action.  He  states  that  "  wherever  they  can  be  applied  locally"  they 
"  modify  most  powerfully  the  diphtheritic  inflammation."  He  dusted  the 
inflamed  surface,  if  accessible,  with  calomel,  or  with  a  powder  of  the  red 
precipitate,  one  part  to  twelve  of  pulverized  sugar.  The  use  of  the  mercu- 
rial collar  for  the  neck  in  the  treatment  of  croup,  employed  and  recom- 
mended by  Bretonneau,  is  familiar  to  those  who  have  read  his  memoirs. 
Professor  Jacobi  also,  who  has  probably  given  more  attention  to  diphtheria 
than  any  other  physician  in  America,  apparently  believes  that  mercury  used 
locally  is  beneficial  in  croup,  for  he  has  recently  recommended  inunction  with 
the  oleate  of  mercury  upon  the  neck,  whenever  the  bichloride  of  mercury 
administered  internally  disagrees.  It  has  seemed  to  me  that  one  or  two 
large  doses  of  calomel  administered  in  the  commencement  of  croup,  when 
there  is  no  decided  cachexia,  do  exert  a  beneficial  action  on  the  course 
of  the  disease,  as  in  the  following : — 

Case — R.  male,  aged  three  years,  began  to  be  croupy,  but  without  any 
marked  impairment  of  the  voice,  on  November  7, 1884.  The  mother  states 
that  he  has  had  sore  throat  nearly  one  week,  but  without  medical  attend- 
ance. He  began  to  be  croupy  on  November  7th,  and  his  respiration 
gradually  became  more  noisy  and  difficult  till  the  evening  of  the  8th, 
when  I  was  asked  to  see  him. 

His  temperature  was  99°.  The  dyspnoea  was  such  that  the  post-clavi- 
cular, supra-sternal,  and  infra-mammary  regions  were  depressed  on  inspira- 
tion, and  his  breathing  was  noisy,  but  the  voice  had  nearly  the  usual 
clearness.    The  fauces,  though  red,  were  not  notably  swollen,  and  a 


336         Smith,  Membranous,  Diphtheritic,  and  True  Croup.  [April 


pseudo-membranous  patch  of  the  size  of  the  nail  of  the  little  finger 
lay  over  the  right  tonsil.  The  diagnosis  was,  therefore  made  of  mild 
diphtheria,  but  with  dangerous  laryngeal  stenosis,  probably  from  the 
presence  of  a  pseudo-membrane;  general  condition  of  the  child  good. 
Six  grains  of  calomel  were  placed  on  the  tongue,  and  inhalation  was 
ordered  by  the  steam  atomizer  of  the  following  : — 

Liquor  potassae,  £j  ; 
Aquae  calcis,  Oj. 

The  record  of  November  10  states  :  Resp.  38  per  minute,  still  noisy,  but 
no  increase  of  dyspnoea ;  pulse  126;  temperature  in  groin  99^°;  slight 
discharge  from  nostrils  ;  uses  the  inhalation  almost  constantly.  From 
this  date  the  pseudo-membrane  and  redness  of  the  fauces  gradually 
disappeared,  and  two  days  later  the  patient  was  out  of  danger. 

The  results  of  the  treatment  of  diphtheria  and  of  the  inflammations 
which  accompany  this  disease  are  liable  to  produce  an  erroneous  opinion 
in  regard  to  the  value  of  therapeutic  agents,  since  cases  differ  so  greatly 
in  type  or  severity.  But  the  experience  of  many  physicians  justifies  the 
belief  that  mercury  and  especially  calomel  employed  within  certain  limits 
in  the  commencement  of  a  pseudo-membranous  inflammation  does  exert 
some  controlling  action  on  this  disease.  That  it  did  much  harm  formerly 
when  physicians  prescribed  it  as  freely  as  we  now  employ  potassium 
chlorate  to  the  extent  in  many  instances  of  increasing  the  cachexia,  and 
causing  mercurialism,  should  not  deter  from  its  judicious  use.  In  the  ordi- 
nary form  of  diphtheria  I  would  not  advise  the  use  of  calomel,  or  would 
limit  its  employment  to  one  or  two  doses  of  six  to  ten  grains  in  the  com- 
mencement of  the  disease  in  robust  cases.  But  in  croup,  since  the  danger 
is  not  from  the  cachexia  or  blood-poisoning  so  much  as  from  the  laryngeal 
stenosis,which  is  apt  to  develop  rapidly,  that  medicine  is  indicated,  and 
should  be  prescribed,  which  most  strongly  retards  the  exudative  process, 
and  aids  in  liquefying  and  removing  the  pseudo-membrane  ;  provided 
that  it  produce  no  deleterious  effect  which  renders  its  use  inadmissible. 
Hence  it  is  proper  to  prescribe  calomel  in  larger  doses  and  for  a  longer 
time  in  the  treatment  of  croup,  than  in  other  forms  of  membranous 
inflammation,  if  it  fulfil  the  indication  as  it  seems  to  in  a  measure.  In 
my  own  practice,  however,  calomel  is  not  prescribed  after  the  first  or 
second  day,  since  I  prefer  the  use  of  other  remedial  measures,  which  are 
efficient,  and  are  less  likely  to  produce  injurious  effects. 

Emetics — These  have  been  largely  used  in  all  forms  of  croup,  and  in 
catarrhal  or  spasmodic  croup  they  usually  produce  marked  relief.  For- 
merly emetics  were  much  employed  in  the  treatment  of  membranous 
croup,  but  now  that  diphtheria  has  spread  throughout  the  country,  and 
most  cases  of  this  form  of  croup  occur  in  patients  suffering  from  diphtheri- 
tic blood-poisoning,  depressing  emetics  as  ipecacuanha  and  antimony  have 
fallen  into  disuse  since  they  were  found  to  be  badly  tolerated.  In  my 
practice  a  child  of  ten  years  with  severe  diphtheria  and  with  commencing 


1885.]     Smith,  Membranous,  Diphtheritic,  and  True  Croup.  337 


croupy  symptoms,  sank  rapidly  and  died  between  two  of  my  visits,  from 
exhaustion  produced  by  a  single  large  dose  of  ipecacuanha  administered  by 
anxious  parents  without  my  advice. 

But  an  emetic  gives  partial  relief  to  the  dyspnoea  in  certain  cases,  since 
it  assists  in  expelling  the  muco-pus,  which  blocks  up  the  tubes  below  the 
pseudo-membranes,  and  sometimes  portions  of  pseudo-membrane  which  are 
easily  detached.  If  an  emetic  be  employed  one  should  be  selected  which 
acts  promptly  with  little  depression,  and  as  a  rule  it  should,  I  think,  only 
be  used  at  the  commencement  of  croup.  If  after  the  initial  period  there 
be  that  degree  of  dyspnoea  which  suggests  its  use,  tracheotomy  is  prefera- 
ble as  more  likely  to  give  relief,  and  save  the  patient.  Of  the  emetics 
which  are  admissible  in  the  commencement  of  croup,  sulphate  of  copper  is 
one  of  the  best.  Several  years  since  in  one  case,  in  which  there  were  at 
my  first  visit  dyspnoea,  croupy  cough,  and  a  pseudo-membrane  over  each 
tonsil,  and  in  which  I  had  made  an  unfavorable  prognosis,  the  parents, 
observing  the  good  effects  of  two  grains  of  sulphate  of  copper,  repeated  the 
dose  every  two  to  four  hours  till  the  following  day,  and  the  patient  recov- 
ered. Such  a  result  however  I  regard  as  exceptional.  Probably  in  ordi- 
nary cases  the  best  emetic  is  the  yellow  sulphate  of  mercury  or  turpeth 
mineral  in  a  powder  of  two  or  three  grains.  The  use  of  this  emetic  in 
croup  was  prominently  brought  to  the  notice  of  the  profession  by  Prof. 
Fordyce  Barker,  who  administered  this  agent  immediately  after  being 
summoned  to  a  case,  and  he  alleges  with  remarkable  benefit  to  his  patients. 
It  has,  however,  been  recently  stated  on  apparently  good  authority  that 
turpeth  mineral  when  it  enters  the  stomach,  although  it  causes  vomiting, 
is  not  itself  ejected  unless  in  small  quantity,  so  that  a  considerable  share 
of  its  action  may  be  through  its  absorption  and  like  that  of  calomel. 

Internal  Disinfectants  or  Germicides  The  theory  which  happens  to 

prevail  regarding  the  nature  of  a  disease  necessarily  influences  the  treat- 
ment. It  is  now  commonly  believed  that  diphtheria  is  produced  by 
bacteria,  and  therefore  the  use  of  agents  which  are  destructive  to  micro- 
organisms is  at  once  suggested  as  the  proper  treatment  for  diphtheria,  and 
for  the  inflammations  which  the  specific  principle  of  diphtheria  gives  rise 
to.  Hence  sulphite  of  sodium,  sulpho-carbolate  of  sodium,  the  phenic 
acid  of  Declat,  and  chlorine  preparations  have  been  administered  internally 
in  the  treatment  of  diphtheria,  but  whether  they  produce  a  better  result 
than  iron  and  potassium  chlorate  is  doubtful. 

But  attention  is  now  widely  drawn  to  the  bichloride  of  mercury,  which 
by  common  consent  is  more  destructive  to  micro-organisms,  when  employed 
locally,  than  any  other  agent  that  can  be  safely  used.  Physicians  in 
search  for  a  remedy  that  would  destroy  micrococci  in  the  system  and  thus 
remove  the  cause  of  diphtheria  were  naturally  led  to  make  trial  of  this 
agent  in  the  hope  that  an  antidote  or  specific  had  been  found.  If  the 
bichloride  can  be  safely  administered  in  doses  sufficiently  large  there  is 


338         Smith,  Membranous,  Diphtheritic,  and  True  Croup.  [April 


every  reason  to  suppose  that  it  will  destroy  microbes  in  the  interior  of  the 
body,  as  well  as  upon  its  surface.  If  clinical  experience  show  that  it  can 
be  used  in  such  doses  without  poisonous  effect,  it  deserves  recognition  as 
the  specific  for  diphtheria.  If,  without  injury  to  the  patient,  it  act 
promptly  enough  to  kill  the  microbe  before  serious  organic  changes  have 
occurred  in  the  organs,  as  granulo-fatty  degeneration  of  the  muscular  fibres 
of  the  heart,  or  nephritis,  it  would  save  many  lives  and  become  as  import- 
ant a  remedy  for  diphtheria  as  quinine  is  for  diseases  produced  by  marsh- 
miasm.  But  unfortunately  we  have  to  deal  with  an  agent  long  recognized 
as  a  deadly  poison,  and  it  is  a  problem  yet  to  be  solved  whether  it  would 
not  destroy  the  patient  if  employed  in  doses  sufficient  to  destroy  the  micro- 
cocci. A  strong  argument  in  favor  of  this  use  of  the  bichloride  was  pre- 
sented to  the  profession  by  Dr.  Thallon,  of  Brooklyn,  in  two  papers 
published  in  the  N.  Y.  Jour,  of  Medicine,  in  April,  1884.  His  argument 
was  substantially  as  follows  : — 

It  has  been  shown  that  the  bichloride  of  mercury  destroys  the  bacteria 
in  a  liquid  having  20,000  times  its  weight.  Now,  if  20,000  grains  of 
blood  are  disinfected  by  one  grain  of  the  bichloride,  7000  or  one  pound  are 
disinfected  by  one-third  of  a  grain.  Prof.  Flint,  Jr.,  states  that,  although 
the  proportionate  quantity  of  blood  in  the  system  varies  in  different  indi- 
viduals, it  may  be  assumed  that  on  the  average  it  is  in  the  proportion  of 
one  to  eight  of  the  entire  weight  of  the  body.  Therefore  one  grain  of  the 
bichloride  would  destroy  the  microbes,  and  disinfect  the  blood,  in  a  child 
weighing  twenty-four  pounds,  two  grains  in  one  weighing  forty-eight 
pounds.  But  if  the  bichloride  can  be  safely  administered  to  a  child  in 
such  doses  that  its  system  contains  one  or  two  grains,  still  it  must  be 
remembered  that  in  diphtheritic  systemic  poisoning  micrococci  occur  in 
the  lymphatics  and  the  tissues,  and  therefore  a  considerably  larger  quan- 
tity of  the  bichloride  is  necessary  to  produce  complete  disinfection  than 
the  quantity  which  is  required  to  disinfect  the  blood. 

But  whether  the  bichloride,  administered  internally,  is  a  safe,  efficient, 
and  proper  remedy  for  diphtheria  must  be.  determined  by  experience.  If 
it  be  shown  to  be  such  by  clinical  observations,  it  should  of  course  be 
administered  in  all  cases,  whatever  be  the  seat  of  the  inflammation.  It 
should  be  administered  in  the  croup  of  diphtheria,  for  if  we  remove  the 
cause  the  inflammations  will  abate  or  can  be  more  successfully  treated. 

A  considerable  number  of  observations  have  been  made  in  the  last  year 
showing  that  adults  badly  tolerate  large  doses  of  the  bichloride.  Thus  one- 
twentieth  of  a  grain  administered  hourly  to  an  adult  with  phthisis  till  seven 
or  eight  doses  were  given  each  day  produced  bloody  diarrhoea  at  the  close 
of  the  third  day,  when  about  one  grain  had  been  taken.  The  same  result 
followed  in  another  adult  when  one-twentieth  of  a  grain  had  been  admin- 
istered every  second  hour  in  the  day  time  only,  for  four  days.  In  a  third 
patient  one-twentieth  of  a  grain  given  hourly  in  the  day  time  for  five  days 


1885.]     Smith,  Membranous,  Diphtheritic,  and  True  Croup.  339 


caused  profuse  salivation  and  pain  in  the  gums  like  that  from  calomel.  A 
fourth  adult  patient  took  one-thirty-second  of  a  grain  hourly  for  eleven 
hours  and  then  one-twenty-sixth  of  a  grain  for  seven  hours,  when  griping 
pain  in  the  abdomen  occurred,  and  liquid  stools.  (Dr.  A.  H.  Smith.) 
One  adult  case  only  is  related  in  the  experiments  of  Dr.  Smith,  in  which 
no  ill  effects  followed  the  administration  of  one-twentieth  of  a  grain  doses 
of  the  bichloride  though  administered  hourly  in  the  daytime  for  eight 
days.  Cases  might  be  mentioned  in  the  practice  of  other  physicians,  show- 
ing that  the  bichloride  is  a  dangerous  remedy  if  given  in  germicide  doses 
in  the  treatment  of  adults.  In  one  instance  in  my  practice  bloody  diar- 
rhoea occurred  on  the  fourth  day  from  the  uterine  douche  used  three  or 
four  times  daily,  and  fatal  cases  have  been  announced  in  the  journals  from 
the  douche. 

But  children  seem  to  tolerate  the  bichloride  better  than  adults,  as  they 
do  arsenic.  It  has  been  largely  used  during  the  last  year  in  New  York 
as  a  remedy  for  diphtheria,  and  especially  for  diphtheritic  croup,  and  phy- 
sicians of  experience  state  that  more  patients  have  recovered  from  croup 
under  treatment  by  the  bichloride  than  from  any  other  medication  which 
they  had  previously  employed.  (Jacobi.)  The  following  brief  statement 
of  the  effects  of  the  bichloride  treatment  in  diphtheria  and  croup  in  a  few 
cases  in  the  practice  of  Drs.  Thallon,  Armor,  Skene,  Jacobi,  and  myself 
will  aid  to  an  understanding  of  the  therapeutic  value  of  this  agent  in 
pseudo-membranous  inflammations. 

Cases  A  child  of      years,  having  diphtheria  after  scarlet  fever,  took 

gr.  hourly,  most  of  the  time  for  one  week,  and  subsequently  the  same 
dose  hourly  in  the  daytime,  and  two  or  three  times  at  night,  with  no  un- 
favorable symptoms  ;  but  the  urine  was  increased  to  70  ounces.  A  child 
of  4  years,  having  croup,  complicating  diphtheria,  and  with  urgent  symp- 
toms, took  gr.  Jg-  of  the  bichloride  every  hour  and  a  half  to  three  hours. 
In  five  and  a  half  days  she  took  more  than  two  grains,  and  in  one  day 
more  than  half  a  grain.  Portions  of  the  pseudo-membrane  were  expec- 
torated, and  the  patient  recovered.  There  were  no  unfavorable  symptoms 
from  the  bichloride. 

Of  five  children  who  recovered  from  the  ordinary  form  of  diphtheria 
reported  by  different  observers,  one,  aged  9  years,  took  gr.  ?L  every  one 
and  a  half  hours,  and  in  one  day  nearly  half  a  grain,  till  the  fifth  day, 
when  a  little  over  two  grains  had  been  taken.  The  second  child,  also 
aged  9  years,  took  nearly  one-half  grain  of  the  bichloride  in  the  first 
twenty-four  hours,  and  in  two  days  three-quarters  of  a  grain.  The  third 
patient,  aged  4^  years,  took  gr.  0f  the  bichloride  every  two  hours  on 
the  first  day,  and  afterwards  at  longer  intervals.  In  the  fourth  case,  a 
child  of  1\  years,  gr.  ^  was  given  every  two  hours,  for  how  long  is  not 
stated,  but  the  membrane  became  less  on  the  second  day.  The  fifth 
patient,  aged  2  years  5  months,  had  a  hoarse  whispering  voice  and  noisy 
(guttural)  respiration;  temperature  105°.  The  pseudo-membrane  ap- 
peared over  the  tonsil  in  considerable  quantity  at  the  close  of  the  second 


340         Smith,  Membranous,  Diphtheritic,  and  True  Croup.  [April 


day.  The  bichloride,  gr.  J¥,  was  given  every  second  hour  alternately  with 
six  minims  of  the  tincture  of  the  chloride  of  iron.  Alkaline  inhalations 
were  constantly  used,  and  one  teaspoonful  of  brandy  given  every  two  hours. 
The  bichloride  was  administered  three  days  with  no  appreciable  ill  effect, 
and  with  gradual  improvement  of  the  patient. 

Although  during  the  last  few  months  the  bichloride  has  been  largely 
used  as  a  remedy  for  diphtheria  and  pseudo-membranous  croup,  in  doses 
like  those  employed  in  the  above  cases,  but  few  instances  have  been  pub- 
lished in  which  it  seemed  to  disagree.  It  has,  however,  in  some  patients 
caused  diarrhoea,  and  apparently  colicky  pains,  as  in  adults,  so  that  it  was 
deemed  advisable  to  discontinue  its  further  use.  According  to  my  obser- 
vation it  does  not  save  life,  or  materially  mitigate  the  intensity  of  the 
disease,  or  the  inflammation,  if  profound  blood-poisoning,  or  grave  com- 
plications, as  nephritis,  have  occurred  when  its  employment  is  commenced. 

The  following  cases,  among  others  which  have  come  under  my  observa- 
tion, show  that  the  bichloride  if  administered  in  grave  cases  at  a  late  stage 
is  powerless  to  save  life  :  A  child  of  3-|  years,  with  malignant  diphtheria, 
took  at  first  the  ordinary  remedies,  such  as  iron  and  potash,  and  when  the 
urine  had  become  heavily  albuminous,  and  the  fauces  much  swollen  and 
covered  with  a  dense  and  foul  pseudo-membrane,  the  bichloride  was  pre- 
scribed in  hourly  doses  of  gr.  -^g.  Two  days  later  death  occurred,  appar- 
ently from  the  blood-poisoning.  Another  patient  of  the  same  age,  and 
nearly  the  same  history,  lived  four  days  under  the  bichloride  treatment. 
Perhaps  better  results  might  have  occurred  from  its  earlier  use. 

Clinical  observations  will  soon  determine  the  actual  value  of  the  bichlo- 
ride in  the  treatment  of  diphtheria  and  diphtheritic  inflammations  ;  and  if 
it  be  a  safe  and  useful  remedy,  whether  its  beneficial  effects  are  due  to  its 
germicide  action,  or  to  the  same  therapeutic  effects  as  those  obtained  from 
other  mercurial  agents.  It  may  be  conveniently  prescribed  in  the  fol- 
lowing formulas  recommended  by  Pepper  and  Thallon  : — 
R. — Hydrarg.  bichlor.,  gr.  ss. 

Tine,  ferri  chloridi,  f^iij. 

Glycerinse,  f^ss. 

Aquge,  q.  s.  ad  f^iij. — Misce. 
One  teaspoonful  every  hour  to  two  hours. 
R. — Hydrarg.  biehlor.,  gr.  ss. 

Elix.  bismuthi, 

Yini  pepsini,  aa  ^iss. — Misce. 
One  teaspoonful  every  hour  to  two  hours. 

It  does  not  seem  necessary  or  prudent  in  ordinary  cases  to  continue  the 
use  of  the  bichloride  more  than  three  or  four  days  in  large  and  frequent 
doses. 

Since  membranous  croup  in  localities  where  diphtheria  prevails  is  in  most 
instances  a  local  manifestation  of  this  disease,  the  same  sustaining  general 
treatment  is  required  which  is  proper  in  ordinary  cases  of  diphtheria. 


1885.]     Smith,  Membranous,  Diphtheritic,  and  True  Croup.  341 

The  tincture  of  the  chloride  of  iron,  administered  every  second  hour  in 
liberal  doses,  potassium  chlorate,  quinine,  brandy  or  other  form  of  alcohol 
in  large  and  frequent  doses,  long  used  in  diphtheria  as  tonics  and  blood 
restorers  are  indicated.  Medicines  of  this  kind  may  be  given  between 
those  which  are  designed  to  correct  the  exudative  process,  and  aid  in 
removing  the  laryngeal  obstruction,  and  which  have  been  described  above. 
The  diet  should  be  nutritious  and  easily  digested,  consisting  largely  of 
milk  and  the  meat  teas.  For  those  with  poor  appetite  and  feeble  diges- 
tion, peptonized  milk,  and  the  peptonized  meat  juices  may  often  be 
advantageously  prescribed. 

Surgical  Treatment  Although  the  best  possible  treatment  by  inhala- 
tions and  internal  medication  be  early  employed  and  without  intermission, 
yet  it  is  the  common  experience  in  all  countries  that  such  treatment  is  in 
a  large  proportion  of  cases  inadequate,  and  that  many  perish  from  suffo- 
cation unless  relieved  by  surgical  interference.  We  have  stated  above, 
that  if  croup  occur  at  the  commencement  of  diphtheria  when  the  exuda- 
tive process  is  active,  and  the  pseudo-membranes  form  rapidly  and  abun- 
dantly, death  is  the  common  result,  if  medicinal  treatment  only  be  em- 
ployed. But  if  the  inflammation  be  less  intense  or  subacute,  as  in  the 
second  week  of  diphtheria,  so  that  there  is  more  time  for  the  action  of 
medicines  and  inhalations,  and  if,  as  is  sometimes  the  case,  the  stenosis 
appear  to  be  at  a  stand-still,  without  any  marked  suffering  from  want  of 
air,  resort  to  surgical  measures  may  be  judiciously  postponed. 

The  indications  for  surgical  interference  are  a  gradual  increase  of  the 
stenosis  and  consequent  dyspnoea,  notwithstanding  the  constant  and  judi- 
cious use  of  remedial  agents,  and  a  manifest  suffering  from  want  of  air  as 
shown  by  restlessness  of  the  child,  and  the  expression  of  suffering  in  his  fea- 
tures, with  or  without  lividity  of  the  surface.  We,  adults,  may  have  some 
faint  conception  of  the  suffering,  which  children  with  acute  laryngeal  ste- 
nosis undergo,  when  we  have  severe  nasal  catarrh  and  attempt  to  breathe 
with  the  mouth  closed,  and  the  paramount  duty  of  the  physician  to  relieve 
suffering  should  prompt  to  a  resort  to  other  measures  when  medicines 
prove  indequate,  even  if  we  leave  out  of  account  the  important  object  of 
saving  life.  When  therefore  membranous  croup  is  found  to  be  progres- 
sive after  having  been  observed  and  properly  treated  from  six  to  twenty- 
four  hours,  and  the  child  begins  to  suffer  from  want  of  air,  the  propriety 
of  surgical  interference  should  be  considered. 

Tubage. — In  1858,  Bouchut  published  a  paper  in  the  Moniteur  des 
Hopit.  on  a  new  method  of  treating  croup  by  tubage  of  the  larynx.  He 
employed  a  straight  cylindrical  tube  nearly  an  inch  long.  The  tube  was 
introduced  by  means  of  a  male  catheter  open  at  its  two  ends.  Tubage 
excited  some  attention  and  discussion  at  the  time  in  the  Parisian  capital, 
and  M.  Gros  related  a  case  of  its  successful  employment.  It  was  found 
in  experiments  on  animals  that  the  tube  caused  ulcerations,  and  as  it  did 
not  produce  the  uniform  relief  which  follows  tracheotomy,  and  was  dis- 


342 


Smith,  Membranous,  Diphtheritic,  and  True  Croup.  [April 


countenanced  by  Trousseau,  Barthez,  and  others,  it  fell  into  disuse,  and 
was  abandoned  as  a  substitute  for  tracheotomy  even  by  those  who  at 
first  warmly  advocated  it.  Recently  Dr.  O.  Dwyer,  of  the  New  York 
Foundling  Asylum,  has  devised  a  tube  of  about  the  same  length,  but  dif- 
fering from  that  of  Bouchut,  from  having  a  greater  antero-posterior  than 
lateral  diameter,  and  therefore  conforming  to  the  shape  of  the  laryngeal 
aperture.  The  left  index  finger,  guarded  by  a  broad  metallic  ring,  is  carried 
far  back  in  the  mouth  of  the  patient  so  as  to  depress  the  root  of  the 
tongue  and  raise  and  fix  the  epiglottis,  and  the  tube  is  introduced  by  a 
curved  handle,  attached  to  its  inner  surface  ;  the  handle  is  detached  by  a 
spring.  The  tube  can  be  readily  removed  by  attaching  the  handle  to  the 
same  fastening  on  its  inner  surface.  Tubing  as  thus  employed  usually 
relieves  laryngeal  stenosis,  and  I  am  not  aware  that  the  instrument  of 
Dr.  O.  Dwyer,  although  employed  in  a  considerable  number  of  instances, 
has  produced  ulceration  or  other  injury  of  the  larynx. 

Case  On  May  21,  1884,  during  my  term  of  service  in  the  New  York 

Foundling  Asylum,  Florence  ,  31  years,  was  admitted  at  the  time 

of  my  visit,  suffering  from  extreme  dyspnoea.  The  symptoms  of  acute 
laryngeal  stenosis  were  so  pronounced,  such  as  great  depression  at  the 
summit  and  base  of  the  chest  on  inspiration,  restlessness,  and  the  appear- 
ance of  anguish  in  the  features  from  want  of  air,  that  the  child  apparently 
could  not  live  more  than  two  or  three  hours  without  relief.  The  fauces 
were  somewhat  hyperaemic,  but  without  pseudo-membrane.  The  tube  was 
applied  by  Dr.  0.  Dwyer,  with  immediate  relief  of  the  dyspnoea,  and  the 
expectation  of  a  large  quantity  of  muco-pus.  Liquid  food  was  readily 
swallowed  when  the  tube  was  present,  but  occasionally  some  of  it  entered 
the  air-passages,  provoking  a  cough.  Three  hours  after  the  insertion  of 
the  tube  the  axillary  temperature  was  102°.  22c?.  Breathing  still  easy; 
axillary  temp.  103°;  pulse,  130.  23d.  The  tube  has  given  complete  re- 
lief ;  a  small  pseudo-membrane  exists  on  each  side  between  the  uvula  and 
tonsils.  28^.  The  tube  was  expectorated  to-day,  and  as  the  respiration 
remained  normal  without  the  tube,  it  was  not  replaced.  30th.  Temp. 
99|°;  pulse  136,  at  times  as  low  as  80;  has  a  loose  cough.  When  the 
tube  was  worn  and  immediately  afterwards  she  expressed  her  wants  in  a 
feeble  whisper,  which  could  be  understood  even  when  the  vocal  cords 
were  covered  by  the  tube.  The  voice  gradually  returned  after  the  expul- 
sion of  the  tube,  and  no  further  treatment  was  required.  The  suffering  of 
the  patient  was  quickly  relieved,  and  her  life  apparently  saved  by  tubage. 

The  tube  when  in  situ  does  not  produce  a  cough,  or  apparently  any 
unpleasant  sensation  in  the  larynx.  Tubage  would  in  my  opinion  come 
into  general  use  as  a  substitute  for  tracheotomy,  were  it  not  for  the  fact 
that  the  pseudo-membrane  in  so  large  a  proportion  of  cases  extends  be- 
yond the  larynx,  and  the  tube  fails  to  relieve  tracheal  and  bronchial 
obstruction.  Since  tracheotomy  gives  equally  prompt  relief  to  the  dys- 
pnoea, and  in  a  larger  number  of  cases,  and  enables  us  to  remove  the 
obstruction  from  the  trachea,  and  to  a  certain  extent  from  the  bronchial 
tubes  through  the  artificial  opening,  the  almost  universal  opinion  in  both 
continents  that  it  is  preferable  to  tubage  or  any  other  surgical  measure, 


1885.]     Smith,  Membranous,  Diphtheritic,  and  True  Croup.  343 


has  a  valid  foundation.  Usually  it  is  best  not  to  defer  tracheotomy,  in 
order  to  make  the  uncertain  trial  of  tubage,  when  the  symptoms  are  so 
urgent  that  surgical  measures  are  required. 

Tracheotomy  Since  diphtheria  has  spread  so  widely,  tracheotomy  has 

become  one  of  the  most  important  operations  in  surgery.  Properly  per- 
formed, and  at  the  proper  time  with  judicious  after-treatment,  it  rescues 
many  children  from  a  most  painful  death.  The  details  of  this  operation 
are  given  in  surgical  treatises,  but  some  general  remarks  relating  to  it  will 
not  be  inappropriate  in  this  paper. 

Sanne  says  that  the  operator  should  have  three  assistants,  at  least  one 
of  them  a  physician.  One  should  administer  chloroform,  one  use  the 
sponge,  and  the  third,  a  physician,  should  be  ready  to  assist  in  handing 
instruments,  ligating  vessels,  etc.  The  operation  is  simple  and  devoid  of 
danger,  or  difficult  and  dangerous,  according  to  circumstances.  The 
younger  the  child,  the  greater  the  danger,  other  things  being  equal.  The 
greatest  difficulty  and  risk  attend  tracheotomy  in  fleshy  infants  with  thick 
and  short  necks,  and  in  patients  who  have  extreme  dyspnoea,  and  are 
nearly  moribund,  so  that  the  operator  is  impelled  to  hurry  on  the  operation 
through  fear  that  death  will  occur  before  the  trachea  is  opened.  The 
operator  should  have  time  for  slow  and  cautious  dissection,  that  he  may 
avoid  wounding  vessels  and  other  important  parts. 

The  patient  to  be  operated  on  should  be  placed  on  his  back  on  a  table 
covered  by  a  blanket,  and  a  bottle  or  block  about  four  inches  in  diameter 
should  be  placed  under  his  neck,  so  that  the  head  is  thrown  back  at  an 
angle  of  forty-five  degrees,  and  the  anterior  surface  of  the  neck  rendered 
prominent.  Chloroform  is  then  administered.  An  incision  should  be 
made  through  the  skin  in  the  median  line  one  and  a  half  to  two  inches  in 
length,  according  to  the  age,  and  extending  to  within  half  an  inch  of  the 
sternum.  Through  the  connective  tissue  to  the  trachea  the  dissection 
should  be  slowly  and  cautiously  made  with  the  point  of  the  knife,  the 
scissors,  and  the  blunt  hooks  which  are  used  to  tear  the  connective  tissue 
and  draw  aside  vessels.  The  tip  of  the  finger  occasionally  pressed  upon 
the  trachea  aids  in  determining  its  location,  and  serves  to  guide  the  dis- 
section which  should  always  be  in  the  median  line.  Little  cutting  is 
required  after  the  skin  has  been  divided,  but  when  fibres  of  connective 
tissue  resist  the  blunt  hooks,  they  should  be  cut  either  by  the  point  of  the 
knife  or  the  scissors.  A  grooved  director  is  also  useful  in  the  dissection, 
since  by  it  the  operator  is  enabled  to  raise  and  tear  resisting  fibres,  or 
detach  them  from  parts  underneath,  so  that  they  can  be  more  readily 
divided. 

Some  surgeons  prefer  the  high,  others  the  low  operation.  In  the  high 
operation  the  trachea  is  found  nearer  the  surface,  and  the  vessels  in  the 
way  are  less  numerous  than  in  the  low  operation.  In  the  operation,  how- 
ever, the  trachea  is  usually  opened  at  that  point,  whether  high  or  low, 
which  is  most  readily  reached  and  laid  bare.    When  this  tube  is  exposed 


344         Smith,  Membranous,  Diphtheritic,  and  True  Croup.  [April 


a  longitudinal  incision  is  made  through  its  anterior  Avail  sufficiently  long 
to  allow  the  canula  to  be  inserted.  It  facilitates  opening  the  trachea  if  it 
be  held  by  a  tenaculum  constructed  for  the  purpose  with  the  hook  bent  so 
as  to  be  at  right  angles  with  the  handle.  The  length  of  the  incision 
through  the  trachea  should  be  about  five-eighths  of  an  inch.  The  canula 
should  not  be  immediately  introduced,  but  the  patient  should  be  made  to 
cough  by  inserting  a  pigeon's  quill  down  the  trachea  into  the  bronchial 
tubes.  Blood,  muco-pus,  and  shreds  of  fibrin,  if  any  be  present,  are  ex- 
pelled through  the  opening  by  the  cough  which  the  quill  produces.  The 
canula  is  now  introduced  with  or  without  the  aid  of  the  tracheal  dilator. 
The  one  which  is  in  common  use  is  that  devised  by  Trousseau,  with  some 
subsequent  improvements.  It  consists  of  two  concentric  cylinders,  the 
external  fenestrated,  and  the  disk  or  plate  which  supports  the  tubes  is 
movable  upon  them. 

The  result  depends  to  a  great  extent  on  the  subsequent  treatment. 
The  common  result  is  immediate  relief  to  the  dyspnoea,  but  unfortu- 
nately in  a  large  proportion  of  cases  the  temperature  rises  about  the 
third  day  after  the  operation,  and  pseudo-membranes  begin  to  form  in 
the  bronchial  tubes,  and  in  some  instances  broncho-pneumonia  results. 
Surgeons  have  endeavored  to  prevent  the  formation  of  membranes  in  the 
bronchial  tubes  after  tracheotomy  by  allowing  lime-water  to  trickle 
through  the  aperture  into  the  tubes;  but  now  that  probably  a  better  solvent 
has  been  discovered  in  trypsine,  a  mixture  of  extractum  pancreatis  and 
sodium  bicarbonate  in  water  or  trypsine  in  a  liquid  state  as  prepared  by 
Fairchild,  should  be  frequently  sprayed  into  the  bronchi  by  the  atomizer 
when  signs  of  bronchial  participation  in  the  disease  begin  to  appear.  No 
surgical  operation  more  imperatively  requires  intelligent  and  attentive  after- 
nursing  than  tracheotomy,  since  the  canula  needs  to  be  often  cleaned  when- 
ever obstructed  by  muco-pus.  The  febrile  movement  alluded  to  above  as 
indicating  the  extension  of  the  inflammation  dowmwards  in  the  tubes  may 
be  in  a  measure  relieved  by  the  application  around  the  chest  of  one  or 
two  thicknesses  of  muslin  wrung  out  of"  cool  water  and  covered  by  oil 
silk.  No  certain  time  can  be  foretold  for  the  removal  of  the  canula  if  the 
patient  live.  If  on  withdrawing  the  inner  tube  and  applying  the  finger 
over  the  end  of  the  remaining  canula,  the  patient  breathe  easily  through 
fenestra,  the  laryngeal  stenosis  has  probably  so  far  abated  that  the  tube 
can  be  safely  removed. 

The  following  is  a  description  of  the  instruments  in  the  tracheotomy 
case  of  one  of  the  most  skilful  operators  in  New  York  City,  Dr.  Fred. 
Lange.    All  of  them  have  small  handles  like  those  of  dental  instruments. 

1.  a.  A  scalpel,  with  cutting  edge  convex,  the  blade  1 J  inches  in  length, 
and  its  greatest  width  ^  inch.  This  scalpel  is  employed  in  dividing  the 
skin  and  in  the  subsequent  dissection,  b.  A  scalpel  of  same  length,  but 
with  narrower  blade  and  straight  cutting  edge,  used  for  opening  the  trachea. 


1885.] 


Win  slow,  Pyloric  Stenosis. 


345 


2.  Two  blunt  hooks,  with  the  h'ook  straight,  \  inch  in  length,  extending 
at  a  right  angle  from  the  handle,  having  a  diameter  scarcely  larger  than  a 
carpet  needle.  The  end  of  the  hook  is  slightly  bulbous.  A  considerable 
part  of  the  dissection  is  performed  by  the  blunt  hooks  which  are  used  in 
tearing  the  connective  tissue. 

3.  Three  artery  clamps,  by  which  bleeding  vessels  or  oozing  surfaces 
are  seized,  and  the  instruments  with  their  points  attached  to  the  bleeding 
surface  are  dropped  upon  the  sides  of  the  neck.  They  thus  aid  in  draw- 
ing open  the  wound. 

4.  Tenacula.  Two  with  hooks  in  line  with  the  handle ;  two  others 
with  hooks  at  right  angle  to  the  handle;  the  diameter  of  the  curves. in 
the  hooks  J  inch.  Those  with  hooks  at  right  angles  are  employed  for 
transfixing  and  holding  the  trachea  when  it  is  to  be  opened. 

5.  Two  grooved  directors,  one  with  the  end  smaller  and  more  pointed 
than  that  of  the  other. 

6.  A  common  artery  forceps,  also  forceps  with  fine  teeth. 

7.  The  spring  hook  of  the  oculist,  employed  by  him  in  separating  the 
eyelids ;  it  holds  apart  the  edges  of  the  wound. 

8.  The  tracheotomy  tube  consisting  of  two  concentric  cylinders,  de- 
scribed above.  • 

9.  Pigeon's  quills  ;  these  are  important  for  removing  muco-pus  and 
fibrinous  shreds  from  the  trachea  and  bronchial  tubes.  An  instance 
has  come  to  my  knowledge  in  which  the  physician  who  assumed  charge 
of  the  case  after  the  operation  attempted  to  use  for  this  purpose  a  small 
piece  of  sponge  held  by  forceps  ;  he  unfortunately  loosened  his  hold,  the 
sponge  was  drawn  in  with  the  breath  and  immediate  death  by  suffocation 
resulted.    This  would  not  have  happened  with  the  pigeon's  quill. 

Dr.  Lange  does  not  stitch  the  wound  by  the  side  of  the  canula,  but 
leaving  it  open,  dusts  upon  it  iodoform,  applies  over  the  iodoform  two 
thicknesses  of  linen  soaked  in  a  bichloride  of  mercury  solution,  one  part 
to  two  thousand,  and  notched  so  as  to  surround  and  pass  under  the  plate 
of  the  canula.  The  linen  is  covered  by  India-rubber  gauze.  Every  hour 
the  linen  is  moistened  by  the  bichloride  solution. 


Article  II. 

A  Statistical  Review  of  the  Operative  Measures  devised  for  the 
Relief  of  Pyloric  Stenosis.  By  Randolph  Wlnslow,  M.A.,  M.D., 
Demonstrator  of  Anatomy  in  the  University  of  Maryland,  and  Professor  of 
Surgery  in  the  Woman's  Medical  College  of  Baltimore  ;  Surgeon  to  University 
and  Bay  View  Hospitals,  Baltimore. 

But  few  of  the  ills  to  which  humanity  has  fallen  heir  are  attended  with 
more  distressing  symptoms  than  those  produced  by  stenosis  of  the  pyloric 


346 


Winslow,  Pyloric  Stenosis. 


[April 


orifice,  from  any  cause  whatever,  and  in  but  few  has  the  prognosis  been 
so  absolutely  hopeless.  Until  within  the  past  six  years  the  condition  was 
regarded  as  beyond  the  domain  of  surgical  interference,  and  with  the 
diagnosis,  "  stenosis  of  the  pylorus,"  the  fate  of  the  patient  was  irrevo- 
cably sealed. 

The  early  history  of  cancer  and  other  affections  of  this  portion  of  the 
alimentary  tract  presents  so  many  features  in  common,  that  it  is  usually 
impossible  to  form  a  correct  diagnosis  until  the  narrowing  of  the  lumen  of 
the  pylorus  has  progressed  to  a  degree  sufficient  to  interfere  with  the 
passage  of  the  contents  of  the  stomach  into  the  duodenum,  or  until  a  per- 
ceptible tumor  is  discovered ;  even  then  many  elements  of  uncertainty 
may  be  present. 

The  cause  of  pyloric  obstruction  in  the  vast  majority  of  cases  is  carci- 
noma, but  the  cicatrization  of  gastric  ulcers,  and  the  thickening  of  the 
walls  in  consequence,  are  occasionally  sufficient  completely  to  close  the 
orifice. 

Symptoms  In  most  cases  of  stenosis  of  the  pylorus  a  tumor  can  be 

discerned  in  the  epigastric  or  right  hypochondriac  region,  even  in  those 
due  to  simple  round  ulcer,  but  sometimes  the  symptoms  of  coarctation  are 
very  decided,  and  no  tumor  can  be  felt.  It  may  be  situated  under  cover 
of  the  liver,  and  beyond  external  exploration.  In  other  cases  the  tumor 
is  displaced  to  the  level  of  the  umbilicus,  or  even  as  low  as  the  pelvis, 
giving  upon  superficial  examination  the  impression  that  the  growth  is  in 
the  great  omentum  or  mesentery.  The  usual  symptoms  of  pyloric  ob- 
struction are  uncontrollable  vomiting  of  the  contents  of  the  stomach,  with- 
out bile,  which  are  sour,  offensive,  and  often  contain  a  sediment  resembling 
coffee-grounds.  Gastric  distress  frequently  amounting  to  severe  pain  is 
often  experienced,  or  a  sensation  of  dragging  or  tearing.  The  stools 
become  more  and  more  scant,  and  occur  at  long  intervals.  With  these 
symptoms  ectasis  of  the  stomach  will  often  be  discovered  upon  careful 
percussion,  or  by  means  of  inflating  the  viscus  with  Seidlitz  powder,  which 
is  made  to  effervesce  within  its  cavity,  or  the  same  can  be  seen  by  intro- 
ducing a  tube  and  filling  the  stomach  with  water. 

Diagnosis  When  symptoms  of  indigestion  have  been  long  in  exist- 
ence, until  finally  the  pain  and  vomiting  have  become  habitual;  when  a 
tumor  is  detected  in  the  pyloric  region  with  which  the  stomach  seems  to 
be  connected ;  and  when  this  organ  is  found  to  be  dilated  by  some  of  the 
methods  mentioned  above,  the  diagnosis  is  almost  certain,  but  with  these 
symptoms  mistakes  have  been  made.  Billroth1  upon  one  occasion 
made  an  incision  for  the  purpose  of  performing  pylorectomy,  and  found 
the  trouble  to  be  a  wandering  kidney,  which  he  removed.  Lauenstein,2 

1  Wien.  Med.  Wochenschrift,  1884,  No.  27. 

2  Arkiv  fur  Klin.  Chirurg.,  Bd.  xxviii. 


1885.] 


Winslow,  Pyloric  Stenosis. 


347 


on  the  contrary,  performed  laparotomy  for  the  removal  of  a  supposed 
floating  kidney,  and  found  he  had  to  deal  with  a  cicatricial  contraction  of 
the  pylorus.  Amongst  other  corroborative  signs  of  carcinoma  of  the 
pylorus  is  the  fact  first  observed  by  Van  den  Velden,  and  substantiated  by 
Czerny,1  that  free  hydrochloric  acid  is  not  found  in  the  stomach  when 
malignant  disease  of  this  opening  is  present.  Mikulicz,2  the  inventor  of 
the  gastroscope,  advocates  the  use  of  this  instrument  for  diagnostic  pur- 
poses. He  says,  when  the  pylorus  is  not  stenosed,  regular  rhythmical 
motions  can  be  seen  to  occur,  but  when  it  is  the  seat  of  cancer,  these 
movements  will  be  absent.  Whilst  ocular  inspection  of  the  stomach  is 
certainly  desirable,  the  gastroscope  is  too  complicated  and  too  expensive 
ever  to  be  available  for  general  use. 

Prognosis — Internal  medicine  offers  absolutely  no  hope  to  the  unfor- 
tunate sufferer  from  pyloric  stenosis,  and  until  recently  he  was  doomed  to 
die  wretchedly  from  starvation.  More  than  seventy  years  ago  Dr.  C.  T. 
Merrem3  proved  beyond  question,  by  experiments  upon  dogs,  that  large 
portions  of  the  stomachs  of  these  animals  could  be  excised  without  neces- 
sarily causing  death,  and  in  a  published  dissertation  earnestly  advocated 
the  propriety  of  the  operation  upon  man  in  appropriate  cases.  His  sug- 
gestion met  with  no  acceptance  from  his  contemporaries,  and  he  did  not 
live  long  enough  to  see  his  views  put  to  the  test  of  practice.  It  remained 
for  a  future  generation,  guarded  by  the  potent  influences  of  antiseptic 
surgery,  to  accept  his  doctrines,  and  venture  upon  removal  of  portions  of 
the  human  stomach.  It  must  not  be  supposed,  however,  that  gastrectomy 
has  been  undertaken  in  our  day  without  careful  experimentation  upon 
animals  and  the  cadaver,  aided  by  observations  upon  man  in  analogous 
conditions  of  the  intestines,  and  accurately  recorded  reports  of  post- 
mortem examinations  of  the  conditions  found  in  carcinoma  of  the  pylorus. 

Pylorectomy  is  a  matter  of  gradual  development,  and  certain  preparatory 
stages  were  required  before  the  operation  was  considered  justifiable  in 
man.  First  in  importance  in  proving  the  feasibility  of  this  operation  has 
been  experimentation  upon  animals,  beginning  with  simple  circular  resec- 
tion of  the  intestines,  and  ending  with  the  almost  complete  removal  of  the 
stomach  and  the  suturing  of  the  cardiac  and  pyloric  extremities  together, 
which  was  successfully  done  by  Kaiser  and  Werth4  upon  a  dog,  the 
animal  not  only  having  been  none  the  worse  for  this  mutilation,  but 
actually  gained  flesh,  and  was  killed  six  years  subsequently,  a  martyr  to 
science.5  Circular  resection  of  the  human  intestines  for  gangrene  caused 
by  hernia,  as  practised  by  Czerny  and  others,  naturally  attracted  profound 

1  Wien.  Med.  Wochens.,  1884,  No.  17. 

2  Wien.  Med.  Wochens.,  1883,  p.  705. 

3  Inaugural  Dissertation.  See  Rydygier's  Lecture,  Volkmann's  Sammlung,  No.  220. 

4  Rydygier's  Lecture,  Volkmann's  Sammlung,  220. 

5  See  Archiv  f.  Klin.  Chirurg.,  1884,  Band  xxx.  Heft  1. 


348 


Win  slow,  Pyloric  Stenosis. 


[April 


attention,  and  the  discovery  of  the  important  fact  that  peritoneal  surfaces 
must  be  brought  flatly  together  in  order  to  obtain  union,  and  the  adapta- 
tion of  the  invaginating  suture  of  Lembert  or  Gely,  and  the  tier  suture  of 
Czerny  have  aided  largely  in  rendering  operative  procedures  upon  the 
stomach  possible. 

Six  operations  have  been  practised  for  the  relief  of  stenosis  of  the 
pylorus:  1st.  Pylorectomy ;  2d.  Gastro-enterostomy ;  3d.  Gastrectomy; 
4th.  Gastrostomy ;  oth.  Duodenostomy ;  6th.  Digital  divulsion  of  the 
pylorus. 

Pylorectomy. — As  previously  stated,  no  operative  treatment  was  ven- 
tured upon  for  the  relief  of  pyloric  disease  until  April  9,  1879,  when 
Pean,  of  Paris,  at  the  urgent  request  of  the  patient,  who  threatened  to 
commit  suicide  unless  relieved  of  his  sufferings,  performed  laparotomy 
and  removed  a  cancerous  tumor  of  the  pylorus,  and  by  so  doing  ushered 
in  a  new  era  in  abdominal  surgery.  His  patient,  a  man,  died  on  the  fifth 
day  of  inanition.  This  operation  attracted  but  little  favorable  notice,  and 
was  regarded  more  in  the  light  of  a  surgical  audacity  than  as  an  advance 
in  the  domain  of  legitimate  surgery.  His  example  was  followed  by  Rydy- 
gier,  of  Kulm,  on  November  16,  1880,  and  his  patient  succumbed  to  col- 
lapse in  twelve  hours.  On  the  29th  of  January,  1881,  Prof.  Billroth,  of 
Vienna,  performed  the  third  pylorectomy  upon  Frau  Maria  Theresia 
Heller,  who  was  dying  from  starvation,  the  result  of  pyloric  stenosis. 
The  patient  made  a  speedy  recovery  from  the  operation,  gained  flesh 
rapidly,  and  returned  to  her  accustomed  mode  of  life.  She  died  from 
recurrence  of  the  disease  four  months  subsequently.  The  news  of  this 
operation  spread  with  wonderful  rapidity,  and  its  successful  issue  was 
hailed  as  a  great  surgical  triumph.  The  surgeons  of  Vienna  especially 
greeted  the  great  event  with  the  liveliest  expressions  of  joy  and  admira- 
tion.   They  called  it  an  epoch-making  operation. 

Statistics  Up  to  the  present  time  pylorectomy  has  been  performed 

over  sixty  times,  in  various  quarters  of  the  globe,  and  although  this  num- 
ber is  insufficient  for  determining  the  true  value  of  the  method,  the  indi- 
cations for  and  against  its  performance,  its  technique,  and  its  final  results, 
still  it  is  believed  that  valuable  data  may  be  gleaned  from  its  statistics, 
meagre  though  they  be.  The  following  table1  is  believed  to  contain  all 
the  recorded  pylorectomies  which  have  been  reported  to  date.  In  almost 
all  of  them  the  original  publications  have  been  examined,  writh  the  excep- 
tion of  those  published  in  the  Norwegian,  Dutch,  Polish,  and  Russian 
languages,  in  which  cases  abstracts  in  the  German  and  American  journals 
have  been  relied  upon  : — 

1  For  previous  statistics  see  Rydygier's  Lecture,  Volkmann's  Sammlung,  No.  220  ; 
Kahn's  tables  in  Bulletin  Gen.  de  Therap.,  tome  civ.  p.  216 ;  and  Kronlein's  tables  in 
Correspondenzblatt  fur  Sehweizer  Aerzte,  July  15,  1882. 


1885.] 


Win  slow,  Pyloric  Stenosis. 


349 


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Retrospect — In  glancing  over  this  table  the  first  thing  to  attract  attention 
will  probably  be  the  very  great  rapidity  with  which  this  operation  became 
popular,  and  possibly  the  fact  that  the  frequency  of  its  performance  has  pro- 
gressively declined  during  the  past  three  years.  If  we  tabulate  the  opera- 
tion by  years  the  following  results  are  obtained  :  In  1879,  Pean  performed 
his  solitary  successful  operation.  In  1880,  one  case  by  Eydygier,  also 
fatal.  1881,  20  cases  were  operated  on  by  16  surgeons,  with  5  recoveries 
and  15  deaths;  or,  25  per  cent,  successful,  75  per  cent,  fatal.  In  1882 
there  were  16  operations  by  15  surgeons,  with  2  recoveries  and  13  deaths, 
one  case  result  unknown  to  me  ;  or,  13^  per  cent,  successful,  83-§  per  cent, 
fatal.  In  1883,  13  operations  were  performed  by  12  surgeons;  6  re- 
coveries and  7  deaths;  successful,  46.15  per  cent. ;  fatal,  53.85  per  cent. 
In  1884,  9  operations  are  all  that  I  can  find  notice  of,  performed  by  5  sur- 
geons, with  6  deaths  and  3  recoveries ;  successful,  33^  per  cent. ;  fatal, 
66-§  per  cent.  In  January,  1885,  one  fatal  case.  Total  operations,  61; 
recoveries,  16,  or  26|-  per  cent.;  deaths,  44,  or  73^-  per  cent.;  result  in 
one  case  unknown  to  me. 

Most  of  these  operations  have  been  performed  in  Austria  and  Germany, 
but  isolated  cases  have  been  operated  on  in  various  portions  of  the  globe. 
In  Austria  18  operations  have  been  performed,  with  8  recoveries,  or  44.44 
per  cent.,  and  10  deaths,  or  55.56  per  cent.  Of  these  cases  Billroth  has 
performed  11,  with  6  recoveries,  54J  per  cent.,  and  5  deaths,  45^  per  cent. 
In  Germany  18  patients  have  undergone  pylorectomy,  with  6  recoveries, 
33 J  per  cent,  and  12  deaths,  66f  per  cent.  Of  German  surgeons,  Czerny 
has  performed  the  most  operations,  4,  with  50  per  cent,  recoveries.  In 
Holland,  2  cases ;  1  recovery  and  1  death  ;  each  50  per  cent.  In  Great 
Britain,  3  cases,  all  fatal.  In  France,  1  fatal  case.  In  Switzerland,  there 
have  been  6  operations,  with  2  recoveries,  33^  per  cent.  In  Italy,  5  cases, 
with  4  deaths;  1,  result  unknown.  In  Russia,  3  cases,  all  fatal.  In  the 
United  States  of  America,  also  3  cases,  which  were  fatal.  Norway  and 
Brazil  are  each  credited  with  1  unsuccessful  case.  From  the  above  classi- 
fication it  is  seen  that  pylorectomy  in  the  hands  of  the  Austrian  surgeons 
has  been  followed  by  44-|  per  cent,  of  successes,  whilst  in  Germany  the 
percentage  of  recoveries  is  33^  per  cent.  Switzerland  has  the  same  aver- 
age, but  with  only  one-third  of  same  number  of  operations,  whilst  Holland 
has  the  highest  average,  50  per  cent.,  but  with  only  2  cases.  The  United 
States  of  America,  Great  Britain  and  Russia,  France,  Brazil,  and  Norway, 
present  a  unanimous  average  of  100  per  cent,  of  deaths.  One  is  forced  to 
recognize  the  fact  that  it  is  in  the  hands  of  Billroth  and  his  special  pupils, 
Czerny,  Mikulicz,  and  Woelfler,  that  the  best  results  have  been  obtained. 
This  is  a  coincidence  which  is  probably  more  than  accidental,  and  bespeaks 
the  skill  of  the  great  Vienna  surgeon,  both  as  an  operator  and  as  the 
teacher  of  skilful  operators. 


1885.] 


Win  slow,  Pyloric  Stenosis. 


353 


Sex  Of  the  61  patients  operated  on,  33  were  women  and  14  men,  the 

sex  of  14  being  unknown  to  me.  Why  there  should  be  such  a  dispropor- 
tion between  males  and  females  I  am  unable  to  say,  but  it  is  probably 
accidental,  as  in  1303  cases  of  cancer  of  the  stomach,  tabulated  by  Wilson 
Fox,1  680  were  males,  and  6*23  females. 

The  ages  of  the  patients  varied  from  25  to  64  years.  Those  in  whom 
recovery  took  place  were  respectively  25,  28,  28,  30,  36,  37,  39,  39,  39, 
42,  43,  43,  52  years  of  age.  Age  seems  to  have  considerable  influence 
upon  the  mortality  of  the  operation,  young  persons  not  succumbing  to  the 
great  depression  as  readily  as  those  who  are  older. 

Duration  of  Operation — The  length  of  time  required  for  the  perform- 
ance of  the  operation  varied  from  1^  to  5  hours.  As  might  be  expected, 
the  long  duration  of  the  anaesthesia,  and  the  cooling  of  the  system  which 
must  occur  in  all  very  protracted  operations,  both,  act  as  powerfully  de- 
pressing agents,  and  the  mortality  is  materially  influenced  thereby.  No 
patient  recovered  where  three  hours  were  consumed  in  the  operation. 

The  amount  of  tissue  removed  varied  greatly,  in  some  cases  nearly  5 
inches  was  excised  from  the  greater  curvature  and  in  several  of  these 
recovery  occurred.  In  two  of  Billroth's  successful  cases  5  inches  (14  cm.) 
were  removed  from  the  greater  curvature,  but  he  finished  the  operation  in 
1±  and  \\  hours  respectively,  the  shortest  time  on  record,  and  the  success 
probably  depends  more  upon  the  celerity  of  the  operation,  than  upon  the 
amount  of  the  gastric  wall  which  is  excised.  In  point  of  quickness  the 
master  Billroth  bears  the  palm,  as  well  as  in  general  excellence  of  results. 

Prognosis. — Whilst  the  result  of  the  operation  depends  much  upon  the  age 
and  strength  of  the  patient,  the  length  of  time  required  for  operation,  and 
the  skill  of  the  operator,  it  depends  more  upon  the  presence  or  absence  of 
adhesions  between  the  stomach  and  the  neighboring  viscera ;  and  the 
determination  of  this  point  is  impossible  until  the  abdomen  has  been 
opened,  and  not  always  then.  It  is  impossible  to  determine  an  absence  of 
adhesions  from  the  mobility  of  the  tumor,  for  in  several  cases  even  after 
the  abdomen  had  been  opened,  the  presence  of  adhesions  was  not  made 
manifest  until  the  operation  had  progressed  to  such  a  point  that  it  was 
utterly  impossible  to  discontinue  it.  This  wras  so  notably  in  the  cases  of 
Langenbeck,  of  Liicke,  and  Jurie.2  Adhesions  to  the  pancreas  are  espe- 
cially dangerous,  and,  if  extensive,  absolutely  contraindicate  the  resection, 
chiefly  on  account  of  the  great  difficulty  in  arresting  hemorrhage,  but  also 
from  the  fact  that  pancreatic  tissue  readily  sloughs,  and  may  allow  the 
secretion  of  the  gland  to  escape  into  the  abdominal  cavity.  In  Eydygier's 
case  of  excision  for  ulcer  there  were  strong  adhesions  to  the  pancreas, 
which  necessitated  the  excision  of  a  considerable  portion  of  its  tissue,  as 

1  Reynolds's  System  of  Med.,  Am.  ed.,  vol.  iii.  p.  106. 

2  Bulletin  Gen.  de  Therap.,  vol.  civ.  p.  216. 


354 


Wins  low,  Pyloric  Stenosis. 


[April 


happened  also  in  one  of  Billroth's  cases.  Both  of  these  cases  were  successful. 
With  few  exceptions,  those  patients  in  whom  there  were  adhesions  to  the 
pancreas  died.  In  the  case  operated  on  by  Berns  the  vena  cava  was 
exposed  for  a  distance  of  three  inches  and  a  portion  of  the  pancreas  excised, 
and  in  the  case  of  Liicke  there  were  many  adhesions,  and  the  portal  vein 
was  laid  bare  for  some  distance.  Extensive  adhesions  to  the  transverse 
colon  also  expose  the  patient  to  great  danger,  on  account  of  the  liability 
to  the  occurrence  of  gangrene,  an  event  which  caused  the  death  of  Lauen- 
stein's  and  Molitor's  patients,  and  both  of  Czerny's.  The  latter  surgeon1 
says  we  must  be  alive  to  this  danger,  and  when  it  is  necessary  to  detach 
the  mesentery  of  the  colon,  a  corresponding  portion  of  the  gut  must  be 
excised.  Diffuse  carcinomatous  infiltration  equally  renders  the  operation 
unjustifiable. 

Indications  for  the  Operation  What  are  the  indications  for  which 

excision  of  the  pylorus  has  been  performed?  1st.  Carcinoma,  which, 
either  on  account  of  unendurable  pain  and  distress,  or  by  the  production 
of  stenosis  and  vomiting,  threatened  death  from  starvation.  2d.  Ulcer  of 
the  stomach,  which,  in  its  cicatrization,  produced  a  sufficient  coarctation 
to  close  the  pyloris.    3d.  Stenosis,  from  swallowing  a  caustic  liquid. 

The  vast  majority  of  these  operations  have  been  performed  on  account 
of  cancerous  disease ;  55  for  this  cause,  5  for  idiopathic  ulcer,  and  1  for 
stenosis  due  to  swallowing  caustic  soda  with  suicidal  intent.  In  those 
reports,  where  the  form  of  malignant  disease  is  distinctly  noted,  it  is  seen 
that  the  mortality  is  very  much  less  in  colloid  than  in  the  other  varieties 
of  cancer.  Thus,  of  7  cases  noted,  5  recovered,  3  of  which  died  from  recur- 
rence at  periods  varying  from  4  to  18  months.  Woelfler's  case  remained 
Iieal thy  one  year,  when  the  disease  recurred  in  the  cicatrix,  which  was 
removed,  and  she  again  left  hospital ;  she  re-entered  the  wards  in  the 
summer  of  1883,  and  is  still  alive,  nearly  four  years  from  the  time  of  the 
primary  operation,  but  with  recurrent  growths  in  the  groin.  Adhesions 
to  the  pancreas  and  other  neighboring  organs  are  found  in  a  large  majority 
of  cases,  and  enlargement  of  the  adjacent  lymphatics  is  almost  always 
present.  I  have  not  noted  the  exact  proportion  of  cases  in  which  adhe- 
sions and  glandular  involvement  were  present,  and  as  the  references  are 
not  accessible  at  the  time  of  writing,  I  will  borrow  from  the  editorial  in 
The  Medical  News,  November  24,  1883,  formed  from  a  study  of  31  cases, 
in  8  of  which  neither  adhesions  nor  glandular  infection  were  noted,  the 
mortality  being  50  per  cent.,  whilst  in  23  these  features  were  present, 
with  only  about  20  per  cent,  of  recoveries. 

When  we  consider  the  great  gravity  of  this  operation,  the  huge  per- 
centage of  deaths,  the  impossibility  of  telling  in  advance  whether  adhe- 
sions are  present  or  not,  the  great  difficulty  in  removing  the  entire  dis- 


i  Wien.  Med.  Wochenschrift,  1881,  Nos.  17,  18,  19. 


1885.] 


Win  slow,  Pyloric  Stenosis. 


355 


ease,  and  the  certainty  of  the  recurrence  of  the  trouble  either  in  situ  or 
by  metastasis,  it  is  to  the  mind  of  the  writer  becoming  more  and  more 
apparent  that  resection  of  the  cancerous  pylorus  ought  not  to  be  performed, 
except  under  very  exceptional  circumstances.  The  number  of  months  of 
life  secured  to  the  few  does  not  compensate  for  the  dreadful  mortality  of 
the  operation.  Quite  otherwise  is  it  with  stenosis  due  to  ulcer  or  to  any 
non-malignant  cause,  not  only  is  the  mortality  25  per  cent,  less,  but  in 
the  cases  in  which  recovery  has  taken  place,  health  has  been  fully  restored. 
The  case  of  Eydygier  was  presented  to  the  Eleventh  Congress  of  German 
Surgeons  eight  months  after  the  resection  had  been  performed,  and  not  only 
was  the  patient  in  robust  health,  but  had  improved  the  time  to  the  extent 
of  being  five  months  advanced  in  pregnancy.  It  is  possible  that  better 
results  might  be  obtained  in  cancer  of  the  pylorus,  if  the  operation  was 
not  performed  as  a  dernier  resort,  but  few  surgeons,  however,  would  be 
willing  to  submit  patients  to  such  a  dangerous  procedure  as  long  as  life 
was  tolerably  endurable,  and  but  few  patients  would  be  willing  to  submit 
to  operation  until  every  other  hope  had  proved  delusive. 

Two  other  indications  are  given  by  Eydygier1  and  von  Hacker2  for  ex- 
cision of  the  pylorus  :  uncontrollable  hemorrhage  from  ulcer  and  perfora- 
tion. In  regard  to  the  first  of  these,  severe  hemorrhage  can  scarcely  ever 
come  into  consideration  as  an  indication  for  this  operation,  as  it  is  gene- 
rally impossible  to  tell  in  advance  what  is  the  cause  of  the  bleeding, 
whether  from  ulcer,  cancer,  simple  inflammation,  or  hepatic  disease.  It 
might,  however,  justify  in  a  very  few  cases  an  exploratory  incision  in  order 
to  determine  the  cause,  and  possibly  the  vessel  might  be  secured,  or  the 
hemorrhage  controlled  by  cautery  or  otherwise.  I  do  not  see  how  the 
presence  of  hemorrhage  could  of  itself  be  an  indication  for  excision.  In 
regard  to  the  perforation  from  ulcer,  it  would  be  the  plain  duty  of  the  sur- 
geon to  perform  laparotomy,  if  the  condition  were  recognized,  or  even  sus- 
pected ;  the  probabilities  would,  however,  be  immensely  in  favor  of  a  fatal 
termination  from  peritonitis,  and  it  appears  to  the  writer  that  such  an 
individual  would  scarcely  be  placed  in  a  more  favorable  condition  by  an 
excision  of  the  pylorus.  It  would  be  better,  when  possible,  simply  to  excise 
the  ulcer  itself,  or  to  invert  the  torn  edges  and  unite  them  with  sutures. 

Causes  of  Death  after  Pylorectomy. — Collapse  is  assigned  as  the  cause 
of  death  in  27  cases,  in  2  of  which  it  was  doubtful  to  the  reporter 
whether  death  was  to  be  attributed  to  simple  collapse  or  to  acute  septi- 
caemia. Of  those  dying  in  collapse,  the  periods  at  which  death  occurred 
are  from  "  a  short  time  after  the  operation"  to  26  hours.  3  died  of  inanition 
and  exhaustion  on  the  5th,  7th,  and  8th  days  respectively.  Peritonitis 
caused  death  in  10  cases,  in  4  of  which  gangrene  of  the  colon  was  present, 

1  Centralblatt  f.  Chirurg.,  Nov.  18, 1882. 

2  Wien.  Med.  Wochenschrift,  1881,  p.  888. 


356 


Win  slow,  Pyloric  Stenosis. 


[April 


due  to  extensive  detachment  of  the  transverse  mesocolon  and  consequent 
interference  with  its  blood  supply.  In  3  other  cases  in  which  peritonitis 
occurred  some  of  the  stitches  were  found  to  have  become  detached,  and 
the  contents  of  the  stomach  had  escaped  into  the  peritoneal  cavity.  In 
two  of  the  cases  in  which  gangrene  of  the  colon  occurred,  there  were  also 
thoracic  complications  of  septic  origin  ;  in  one  pyopneumothorax,  in  the 
other  pleurisy. 

From  these  items  we  learn  that  almost  50  per  cent,  of  all  those  subjected 
to  resection  of  the  pylorus  have  succumbed  in  less  than  26  hours  from  col- 
lapse ;  the  patients  not  having  had  sufficient  vitality  to  react  from  the 
prolonged  and  depressing  operation.  16^  per  cent,  of  all  cases  died  from 
peritonitis,  from  one  or  another  cause  ;  in  several  having  been  caused  by 
the  premature  loosening  of  the  sutures.  This  is  a  recognized  danger 
which  should  be  guarded  against  by  a  careful  revision  of  the  lines  of  union. 
Gangrene  of  the  colon  has  proven  an  unexpected  and  very  urgent  danger, 
and  it  should  be  guarded  against  by  detaching  the  mesocolon  as  little  as 
possible,  and  when  extensive  detachment  is  necessary,  by  resection  of  the 
corresponding  portion  of  the  colon. 

Technique  of  the  Operation — It  would  occupy  too  much  time  and  space 
to  enter  minutely  into  a  discussion  of  the  technique  of  pylorectomy ; 
besides  it  would  be  only  repeating  that  which  is  already  well  known  to 
most  surgeons.  Those  who  are  interested  in  learning  more  in  detail  the 
various  steps  of  the  operation,  I  would  refer  to  the  translation  of  Dr. 
Woelfler's  pamphlet,  "  Uber  die  von  Herrn  Professor  Billroth  Ausgefuhrten 
Resectionen  des  carcinomatosen  Pylorus,"  appended  to  Billroth's  Clinical 
Surgery,  published  by  the  New  Sydenham  Society  in  1881 ;  to  Wiener 
Medizinische  Presse,  1881,  vol.  xxii.  p.  770  ;  or  to  Rydygier's  excellent 
lecture  in  Volkmann's  Sammlung  Klinischer  Tui^vige,  No.  220.  I  will 
content  myself  with  presenting  here  only  a  brief  outline  of  the  operative 
acts. 

Preliminary  Preparation — Several  days  previous  to,  and  again  shortly 
before  the  operation,  the  stomach  ought  to  be  thoroughly  evacuated  and  its 
cavity  well  irrigated  with  some  antiseptic  solution;  salicylic  acid  1-1000, 
being  that  which  is  used  by  many  surgeons.  This  can  be  effected  readily 
by  an  ordinary  stomach  tube  or  piece  of  large  drainage  tube,  into  the  end 
of  which  a  funnel  is  inserted  ;  the  patient  being  in  a  sitting  posture. 
Water  is  allowed  to  flow  into  the  stomach  until  it  is  filled,  then  by  de- 
pressing the  end  of  the  tube,  or  by  causing  the  patient  to  assume  the  prone 
position,  the  current  will  be  reversed  and  the  viscus  emptied.  In  this,  as 
in  abdominal  operations  in  general,  the  observance  of  those  important 
surgical  principlesof  cleanliness  and  antisepsis  is  of  the  utmost  importance. 

The  operation  itself  is  divided  into  five  stages  : — 

1st  Stage.  The  abdominal  incision — It  is  a  matter  upon  which  there 
is  considerable   difference  of   opinion    as  to  the  best  position  for  the 


1885.J 


Winsloav,  Pyloric  Stenosis. 


357 


abdominal  incision.  Billroth  prefers  a  transverse  or  an  oblique  incision 
over  the  most  prominent  portion  of  the  tumor,  which  in  his  opinion  affords 
better  access  to  the  seat  of  disease,  but  Czerny,  who  is  the  next  most 
experienced  and  skilled  operator,  and  Rydygier,  as  well  as  several  other 
surgeons,  made  their  incisions  in  the  middle  line,  and  found  it  to  answer 
every  purpose.  There  are,  perhaps,  but  few  cases  in  which  an  incision  in 
the  linea  alba  will  not  give  sufficient  space,  and  when  such  is  the  case,  it 
would  not  complicate  the  operation  much  to  make  an  additional  transverse 
cut.  It  is  certainly  more  difficult  to  maintain  accurate  apposition  of  the 
incision  when  the  muscles  have  been  divided  transversely  ;  and  in  one 
case  peritonitis  began  at  the  transverse  incision.  Having  opened  the 
abdomen  the  first  duty  of  the  surgeon  is  to  see  whether  the  tumor  has 
contracted  such  adhesions  as  will  prevent  a  total  extirpation  of  the  disease, 
or  which  will  render  the  operation  long  and  difficult.  Equally  important 
is  it  to  ascertain  whether  the  malignant  disease  is  diffused  or  confined  to 
the  pylorus  and  adjacent  stomach  wall.  If  the  adhesions  are  great,  or 
the  disease  disseminated,  the  operation  must  be  discontinued  and  the 
abdomen  closed  ;  or  if  the  stenosis  is  marked  a  gastroenterostomy  must 
be  performed. 

2d  Stage.  Isolation  of  the  tumor. — The  isolation  of  the  pyloric  tumor  is 
effected  by  ligaturing  the  greater  and  lesser  omenta  in  small  portions  with 
double  ligatures,  and  cutting  between  the  threads.  The  omenta  must  only 
be  detached  to  a  point  corresponding  to  the  line  of  the  proposed  excision, 
otherwise  gangrene  of  the  stomach  or  duodenum  might  occur.  Warm 
carbolized  or  sublimated  towels  or  pieces  of  gauze,  or  large  flat  sponges, 
are  now  pushed  under  the  stomach,  and  the  rest  of  the  operation  becomes 
extra-peritoneal  to  a  large  extent,  any  blood  or  intestinal  contents  being 
absorbed  by  the  compresses. 

3d  Stage.  Resection  of  the  diseased  portion. — The  stomach  is  now 
secured  by  the  hands  of  an  assistant  or  clamped  with  forceps  or  rods 
covered  with  rubber,  and  it  is  divided  from  the  smaller  curvature  ob- 
liquely downward  from  the  left  to  the  right.  The  difference  between  the 
lumina  of  the  stomach  and  duodenum  is  to  be  overcome  by  bringing 
together  the  upper  portion  of  the  incision  in  the  stomach,  leaving  an  open- 
ing at  the  greater  curvature  of  a  size  to  correspond  with  the  duodenum. 
In  effecting  this  occlusion  of  the  upper  part  of  the  incision,  the  mucous 
surfaces  are  first  united  with  internal  sutures,  and  then  the  serous  surfaces 
are  inverted  by  the  Lembert  suture,  about  one-third  of  an  inch  of  the 
peritoneum  being  included  in  each  suture,  which  is  so  passed  as  not  to 
penetrate  the  mucous  membrane,  and  finally  a  row  of  interrupted  or  con- 
tinuous sutures,  the  whole  forming  the  "  tier"  suture  of  Czerny.  Pean  and 
Pydygier  employed  catgut  for  suture,  but  strong  silk  rendered  aseptic  is 
more  durable  and  equally  as  unirritating.  Several  modifications  have 
been  introduced  by  various  surgeons,  thus  some  prefer  the  hands  of  an 


358  "Winslow,  Pyloric  Stenosis.  [April 

assistant  to  clamps  for  preventing  the  escape  of  the  gastric  and  intestinal 
secretions,  whilst  others  prefer  mechanical  occlusion  as  being  more  certain 
and  less  liable  to  accidents  than  that  by  the  hand.  After  the  division  and 
occlusion  of  the  stomach,  the  duodenum  is  divided  and  the  diseased  por- 
tion removed.  Hemorrhage  should  be  prevented  by  ligating  the  vessels 
as  they  are  cut,  hence  it  is  recommended  to  divide  the  parts  in  successive 
cuts,  stopping  to  seize  the  vessels.  Kocher  in  addition  recommends  and 
practised  successfully  the  crushing  of  a  limited  zone  with  forceps. 

4th  Stage.  .Reunion  of  stomach  and  duodenum — As  the  result  of  expe- 
rience all  operators  now  prefer  to  insert  the  duodenum  upon  the  greater 
curvature  of  the  stomach.  This  is  effected  by  a  double  or  treble  row  of 
sutures  ;  beginning  from  within,  the  posterior  walls  of  the  viscera  are  united 
by  sutures  which  are  entered  and  brought  out  between  the  mucous  and 
muscular  coats  and  in  effect  make  a  Lembert  suture,  only  they  are  tied 
from  within  ;  the  mucous  surfaces  are  then  sutured  separately  all  around. 
The  union  of  the  anterior  portion  is  effected  by  ordinary  Lembert  sutures, 
with  an  additional  tier  of  interrupted  or  continuous  stitches.  After  care- 
fully inspecting  all  the  sutures  in  order  to  be  sure  of  their  security,  the 
parts  are  cleansed  and  disinfected  and  replaced. 

5th  Stage.  Closure  of  abdominal  incision — This  is  effected  in  the  usual 
manner;  when  the  incision  is  transverse,  it  will  be  necessary  to  employ 
great  care  in  carefully  approximating  the  edges  and  in  supporting  them 
by  deep  relaxation  sutures.  An  antiseptic  dressing  completes  the  opera- 
tion. After  the  operation  nourishing  enemata  are  to  be  administered 
regularly  every  three  hours,  and  only  cracked  ice  allowed  by  the  mouth. 
By  the  next  day  small  quantities  of  milk  or  fluid  may  be  permitted,  and 
if  the  case  progresses  favorably  solid  food  can  be  borne  by  the  second 
week. 

The  operative  technique  is  already  nearly  perfect,  but  it  can  rarely  be 
completed  under  two  hours,  and  usually  the  patient  is  in  a  condition  of 
profound  shock  at  its  termination,  from  which  he  frequently  fails  to  rally. 

Results  of  Pylorectomy — From  a  consideration  of  the  statistics  of  pylo- 
rectomy  for  all  causes,  we  learn  that  26§  per  cent*  of  those  operated  on 
have  survived  the  operation,  and  73^  percent,  have  succumbed  to  causes 
set  in  motion  by  the  procedure,  the  vast  majority  perishing  in  collapse 
within  twenty-four  hours. 

Of  the  operations  performed  for  carcinoma  24  per  cent,  recovered  and 
76  per  cent.  died.  Of  those  who  recovered,  the  first  died  4  months  sub- 
sequently from  recurrence.  The  second,  Woelfler's  case,  is  still  alive  nearly 
four  years  subsequently,  but  has  already  submitted  to  one  or  more  opera- 
tions for  the  removal  of  recurrent  growths  of  the  abdominal  wall,  and  has 
now  an  enlargement  of  the  inguinal  glands.  She  looks  well,  however.  The 
3d  case  died  in  18  months  ;  the  4th  in  10  months  ;  the  5th  in  1  lj  months  ; 
the  6th  in  15  months  ;  the  7th,  Mikulicz's,  is  probably  still  alive  ;  the  8th, 


1885.]  Win  slow,  Pyloric  Stenosis.  359 

Billroth's,  alive  but  with  recurrence;  the  9th,  Socin's,  after  having  made  a 
wonderfully  rapid  recovery,  went  to  work  and  supported  her  family,  but 
the  disease  recurred,  and  11  months  subsequently  gastroenterostomy  was 
successfully  performed,  and  at  last  report,  4  months  subsequently,  she  was 
again  working  for  her  living,  Of  the  10th  case,  Heineke's,  I  have  no 
knowledge,  nor  of  the  11th,  Kocher's ;  both  were  performed  late  in  1883, 
and  are  probably  alive.  The  12th  and  13th,  performed  about  one  year 
ago  by  Billroth,  are  alive  and  free  from  disease.  The  fact  is  indisputably 
proven  that  no  case  of  cancer  of  the  pylorus  has  been  extirpated  with  the 
final  result  of  a  cure  lasting  over  three  years  without  recurrence.  This 
fact,  alone,  however,  ought  not  to  deter  one  from  the  operation  but  for  the 
very  great  mortality  incident  to  it.  6  cases  of  non-carcinomatous  stric- 
ture of  the  pylorus  have  been  resected,  with  50  per  cent,  of  recoveries. 
In  those  who  have  recovered  it  is  probable  that  the  final  results  are  per- 
fect. Eydygier  presented  his  patient  to  the  11th  Congress  of  German 
Surgeons  eight  months  later,  and  she  was  not  only  in  robust  health,  but  was 
advanced  five  months  in  pregnancy.  Dr.  Von  Hacker  writes  me  in  regard 
to  the  case  operated  on  by  Billroth  last  year,  that  it  is  "  radically  cured." 

Gastro-enterostomy  This  operation  was  first  performed  by  Dr. 

Anton  Woelfler,  of  Vienna,  on  September  27,  1881.  It  was  devised  upon 
the  spur  of  the  moment,  as  a  substitute  for  pylorectomy  in  a  case  in  which 
excision  was  rendered  inadmissible,  owing  to  extensive  adhesions  of  the 
pylorus  to  the  pancreas.  As  there  was  a  high  degree  of  stenosis  present, 
and  the  man  was  dying  from  inanition,  it  was  decided  to  attempt  to  afford 
an  exit  for  the  gastric  contents  by  establishing  a  communication  between 
the  stomach  and  a  neighboring  loop  of  small  intestine.  The  patient  was 
thirty-eight  years  of  age,  and  presented  the  usual  symptoms  of  pyloric 
cancer.  Upon  the  above  date,  Dr.  Woelfler  prepared  to  perform  resection, 
but  after  opening  the  abdomen  found  the  conditions  too  unfavorable,  and 
rejecting  duodenostomy,  the  only  other  alternative,  he  simply  raised  the 
nearest  loop  of  small  intestine,  and  after  making  an  incision  one  and  one- 
half  inches  in  length  in  the  free  border  of  the  gut  and  in  the  anterior 
stomach  wall  near  the  great  curvature,  united  the  edges  of  the  two  openings 
with  Lembert  sutures.  The  result  was  all  that  could  have  been  expected, 
the  patient,  who  had  been  vomiting  incessantly  for  three  months,  ceased 
to  regurgitate  his  food  immediately,  and  in  a  few  days  well-formed  stools 
were  passed,  and  the  bodily  condition  of  the  patient  rapidly  improved. 
He  lived  four  months  after  the  operation,  a  period  of  time  exactly  equal 
to  that  of  Billroth's  first  resection.  Gastro-enterostomy  has  been  per- 
formed for  all  causes,  thirteen  times,  as  far  as  I  can  ascertain.  It  is  easier 
to  perform  than  pylorectomy,  takes  less  time  to  accomplish,  and  exposes 
the  patient  to  fewer  risks.  The  following  table  contains  all  the  operations 
recorded  to  date  : — 


360  Win  slow,  Pyloric  Stenosis.  [April 


Statistical  Summary  of  all  Cases  of  G  astro-enter  ostomy 


No. 

Operator. 

Residence^ 

Date. 

Sex. 

Age. 

Disease. 

Duration  ot 
operation. 

1 

Woelfler 

Vienna 

1881 

M. 

3S 

Carcinoma 

? 

Sept.  27 

2 

Billroth 

Vienna 

18S1 

M. 

45 

Carcinoma 

1  hour 

Oct.  2 

3 

Lanenstein 

Hamburg 

18S1 

M. 

50 

Carcinoma 

2  hours 

Dec.  15 

4 

Rydygier 

Kulm 

18S2 

M. 

54 

Carcinoma 

? 

May 

5 

Liicke 

Strassburg 

1SS2 

F. 

? 

Carcinoma 

? 

May 

6 

Kocher 

Berne 

1882 

M. 

50 

Carcinoma 

? 

June  5 

7 

Lauenstein 

Hamburg 

1882 

F. 

25 

Carcinoma 

? 

S 

Courvoisier 

Basle 

18S3 

F. 

56 

Carcinoma 

2  hours 

Oct  19 

50  min. 

9 

Woelfler 

Vienna 

1883 

,  ? 

? 

Carcinoma 

? 

10 

Rydygier 

Kulm 

1884 

M. 

20 

Stenosis  of  duodenum 

? 

March  13 

from  ulcer. 

11 

Monastyrski 

Russia 

1884 

M. 

36 

Stenosis  from  swallow- 

2 hours 

ing  sulphuric  acid. 

12 

Ransohoff 

Cincinnati 

18S4 

M. 

34 

Carcinoma 

? 

April  12 

13 

Sociu 

Basle 

1884 

F. 

44 

Recurrent  carcinoma 

14.  hours 

June  5 

From  this  table  it  will  be  seen  that  gastro-enterostomy  was  devised  as 
a  substitute  for  pyloric  resection  in  those  cases  in  which  extensive  diffu- 
sion of  the  disease  rendered  excision  impracticable,  and  in  which  marked 
stenosis  of  the  pylorus  prevented  the  passage  of  the  chyme  into  the  duode- 
num. It  is  then  an  operation  which  does  not  aim  at  the  production  of  a 
radical  cure,  but  only  of  a  temporary  relief  of  the  vomiting  and  distress 
due  to  obstruction.  In  but  one  case  does  it  appear  that  this  procedure 
was  performed  upon  a  patient  on  whom  pylorectomy  could  have  been 
easily  accomplished.  Our  countryman,  Dr.  Ransohoff,  performed  gastro- 
enterostomy upon  a  patient  upon  whom  pylorectomy  could  have  been 
readily  carried  out,  but  as  he  was  exceedingly  debilitated  it  was  judged 
best  to  establish  a  gastro-jejunal  fistula,  as  being  a  less  severe  and  shorter 
operation,  and  one  which  in  the  light  of  recorded  pylorectomies  offered 
at  least  as  good  a  chance  of  prolonging  life.  The  early  death  of  his 
patient,  of  collapse,  at  least  evinced  the  wisdom  of  declining  the  longer 
operation. 

Dr.  Rydygier  performed  gastro-enterostomy  for  other  cause  than  exten- 
sive cancerous  disease;  his  patient  suffered  from  stenosis  due  to  duodenal 
ulcer,  and  the  channel  for  the  food  was  diverted  by  uniting  the  stomach 
and  jejunum. 

Monastyrski  also  performed  gastro-enterostomy  for  non-malignant  ste- 
nosis. In  the  reported  cases,  thirteen  in  number,  only  four  have  recovered 
from  the  operation,  but  too  unfavorable  conclusions  must  not  be  drawn 
from  this  fact  alone,  as  the  condition  of  these  patients  was  such  as  to  have 
caused  death  in  a  short  time  without  any  operation.    It  seems  to  me  that 


1885.]  "Win slow,  Pyloric  Stenosis. 

recorded  up  to  February  1,  1885. 


361 


No.  Result. 


Cause  of  death. 


Remarks. 


1  Kecovery,    Cancerous  adhesions 

I     prevented  resection 

2  Death  on,  Obstruction  from  bend-   Cancerous  adhesions 


13 


10th  day  I 
Death  on| 

3d  day 
Death  on, 

4th  day  | 
Recovery 

Death  on 
3d  day  I 
Death  in 
4  weeks 
Death  in 
12  days 
Death 
soon 
Recovery 

Death 
same  day 
Death  in 

8  hours 
Recovery 


ing  of  intestine. 
Exhaustion 

Hemorrhage  from 
wound 


Bending  of  intestine 
Marasmus 
Peritonitis  and  abscess 


prevented  resection 
Disease  too  diffuse  for 
resection. 

Dis  too  diffuse  for  resec- 
tion; glands  involved 


Cancer  diffused  ;  steno- 
sis marked 

Metastatic  disease  of 
liver 

Cancer  diffused 


Reference. 


Collapse 
Collapse 


Duodenum  was  strictur'd 
near  pylorus,  from  ulcei 


Pylorectomy  could  have 
perf'med  but  for  asthenia 
Pylorectomy  had  been 

successfully  performed 

on  July  15,  1S83 


Central blatt  fur  Chirg., 

1881,  No.  45. 
Ibid. 

Archiv  fiir  Klin.  Chirg., 

Bd.  xxviii.  p.  420. 
Centralblatt  fiir  Chirg., 

18S3,  p.  241. 
Deutsche  Zeitsch.  fur  Chirg., 

1SS2,  Bd.  xvii.  p.  573. 
Corresp.  bl.  fiir  Schw.Aerzte, 

Dec.  1,  18S3. 
Virchow,  Archiv,  1834,  Bd. 

ii.  2abtheil. 
Corresp  bl.f.  Schw.  A.evzte, 

Dec.  1,  18S3. 
Med.  Times  and  Gazette, 

London,  Oct.  27,  1883. 
Centralblatt  f.  Chirg.,  1884, 

Beilage  to  23. 
Centralblatt  f.  Chirg.,  1834, 

p.  352. 

Med.  News,  Nov.  22,  18S4, 
p.  57S. 

Corresp.  bl.  f.  Schw.Aerzte, 
Nov.  1,  1884,  p.  513. 


this  method  is  especially  applicable  to  ulcer  of  the  stomach,  and  that  its 
most  valuable  application  might  perhaps  be  found  in  this  affection.  Ulcus 
ventriculi  is  frequently  situated  at  the  pylorus,  and  is  consequently 
irritated  by  the  passage  of  food  over  its  surface.  It  might  gain  more 
physiological  rest  if  an  opening  were  made  elsewhere  ;  at  any  rate,  its 
cicatrization  would  not  prevent  the  onward  passage  of  the  contents  of  the 
stomach. 

The  technique  of  the  operation  is  sufficiently  simple  :  a  transverse  inci- 
sion over  the  stomach,  the  raising  of  the  nearest  piece  of  jejunum,  and 
the  attachment  of  its  free  border  to  the  greater  curvature  of  the  stomach 
by  means  of  interrupted  sutures  to  the  edges  of  the  incision,  and  Lembert 
sutures  to  the  peritoneal  and  muscular  coats.  The  intestine  must  be 
clamped  above  and  below  the  point  at  which  the  incision  is  to  be  made. 
The  opening  between  the  stomach  and  intestine  ought  to  be  one  to  one- 
and-one-half  inches  in  length. 

Comparisons  Let  us  examine  a  little  more  closely  the  causes  of  death 

following  this  operation,  and  the  periods  at  which  the  fatal  event  occurred, 
and  in  that  manner  we  may  be  able  to  reach  a  more  accurate  comparison 
of  the  dangers  and  results  incident  to  gastroenterostomy  and  pylorectomy. 
Of  13  cases  operated  on,  9  have  died  at  periods  varying  from  8  hours  to 
4  weeks ;  hence  the  proportion  of  recoveries  is  about  30f  per  cent.  Of 
11  cases  operated  on  for  carcinoma,  3  recovered,  or  27^  per  cent.  Of  the 
first  13  cases  of  pylorectomy,  3  recovered,  or  23  per  cent.  Of  the  first  11 
cases  operated  on  for  carcinoma,  2  recovered,  or  18^  per  cent. ;  hence  it 
is  seen  that  the  advantage  is  in  favor  of  gastroenterostomy.  It  is  scarcely 


362 


"Wins  low,  Pyloric  Stenosis. 


[April 


fair  to  compare  the  results  of  an  operation  which  has  been  performed  only 
13  times,  with  the  average  results  of  one  which  has  been  performed  five 
times  as  often,  though  even  when  the  average  of  the  whole  number  of  pylo- 
rectomies  is  compared  with  that  of  gastro-enterostomy,  it  will  not  be  to  the 
disadvantage  of  the  latter.  It  is  a  noticeable  fact  that  only  3  have  died 
from  collapse;  whilst  in  the  first  13  pylorectomies  8  died  within  26  hours 
from  this  cause.  There  seems,  however,  one  danger  inherent  to  this  ope- 
ration, which  is  the  liability  of  the  portion  of  intestine  which  has  been 
attached  to  the  stomach  to  form  an  angle,  thereby  interfering  with  the 
passage  of  the  contents  of  the  duodenum  and  stomach  onwards.  This 
occurred  in  Billroth's  and  Kocher's  cases,  and  caused  death  in  each,  on 
the  10th  day  in  one,  and  the  3d  in  the  other.  This  accident  can  be  pre- 
vented by  uniting  a  greater  extent  of  intestine  to  the  stomach.  The 
remaining  deaths  were  from  exhaustion,  hemorrhage  from  the  wound,  and 
peritonitis,  and  in  the  second  case  of  Lauenstein,  which  survived  four 
weeks,  and  might  properly  be  classed  amongst  the  recoveries,  from  maras- 
mus and  metastatic  disease  of  the  liver.  Courvoisier's  case  lived  nearly 
two  weeks,  and  died  of  peritonitis,  due  to  an  abscess,  not  having  any  con- 
nection with  the  seat  of  operation,  which  was  found  to  be  well  healed. 

Whilst  the  statistics  of  this  operation  at  present  only  show  30  per  cent, 
of  recoveries,  there  is  but  little  doubt  that  if  it  had  been  performed  before 
the  condition  of  the  patients  became  so  desperate,  the  successes  would  have 
been  much  more  numerous.  If,  for  example,  in  1882,  when  13  pylorec- 
tomies, with  but  two  recoveries,  were  done,  these  patients  had  been  sub- 
mitted to  gastro-enterostomy,  it  is  entirely  probable  that  the  results  would 
have  been  much  better.  Of  the  cases  which  recovered,  2  survived  more 
than  4,  and  one  more  than  6  months,  whilst  the  case  of  duodenal  stricture 
was  probably  permanently  relieved.  Here  the  advantage  is  on  the  side  of 
pylorectomy,  for  of  the  first  3  recoveries,  one  died  in  4  months  ;  the  2d, 
Woelfler's,  is  still  alive,  almost  4  years  from  the  original  operation,  as  I 
have  just  learned  through  the  kindness  of  Dr.  Hitter  von  Hacker,  assist- 
ant on  Prof.  Billroth's  clinic.  The  3d  recovery,  that  of  Czerny,  died  in 
18  months.  The  sum  total  of  extension  of  life  divided  amongst  the  3 
gives  each  about  22^  months.  Of  10  recoveries  after  pylorectomy  for 
carcinoma,  the  dates  of  whose  deaths  are  known,  or  who  are  known  to  be 
still  alive,  an  average  of  16  months  of  life  has  been  gained.  Now  whilst 
these  results  are  good,  and  will  doubtless  increase  in  excellence  as  sur- 
geons become  more  skilled  in  the  performance  of  pylorectomy,  it  becomes 
a  very  serious  question  whether  gastro-enterostomy  by  giving  a  shorter 
lease  of  life  to  more  patients,  is  not,  on  the  whole,  to  be  preferred.  If 
the  patient  is  strong,  and  adhesions  are  absent,  pylorectomy  may  be  ad- 
missible, but  if  the  patient  is  much  run  down,  or  there  are  adhesions  to 
the  pancreas,  or  glandular  infiltration,  there  can  be  no  doubt  that  gastro- 
enterostomy ought  to  be  performed.    Neither  operation  is  radical,  and 


1885.] 


Wins  low,  Pyloric  Stenosis. 


363 


that  which  will  bring  temporary  relief  to  the  greatest  number  ought  to 
be  adopted.  There  is  a  class  of  patients  whose  lives  are  being  slowly 
consumed  with  hunger  and  pain,  upon  whom  it  is  proper  to  attempt,  by 
operative  means,  to  secure  a  measure  of  comfort  during  their  remaining 
days  or  months  of  existence,  and  at  last  to  obtain  for  them  an  euthanasic 
end.  This  I  believe  can  be  accomplished  by  gastro-enterostomy  as  far  as 
it  is  possible  for  any  operation  to  accomplish  it. 

Gastrectomy  Amongst  exceptional  measures  attempted  for  the 

relief  of  pyloric  stenosis,  due  to  extensive  cancerous  disease,  may  be 
mentioned,  total  extirpation  of  the  stomach,  by  Connor,  of  Cincinnati. 
The  operation  was  undertaken  on  December  7,  1883,  at  the  urgent 
request  of  the  patient,  a  woman,  fifty  years  of  age,  and  was  not  completed, 
the  patient  dying  upon  the  table  from  shock.  "  He  had  hoped  in  his  case 
to  be  able  to  get  the  cardiac  end  of  the  stomach  attached  to  some  portion 
of  the  intestinal  tract,  he  did  not  care  much  where,  so  that  the  fluids 
poured  out  in  the  upper  part  of  the  small  intestine  might  flow  down  to 
meet  the  food,  and  cause  digestion  in  the  part  of  the  intestine  where  they 
come  together.  The  operation  he  considered  perfectly  feasible,  as  far  as 
the  operative  procedures  are  concerned."1  A  gastro-enterostomy  would 
have  given  the  patient  a  better  chance  for  life. 

Gastrostomy  Gastrostomy2  was  performed  by  Hahn,  of  Berlin,  in 

one  case  and  a  tube  passed  through  the  pylorus  into  the  duodenum  with 
the  result  of  prolonging  the  life  of  the  patient  three  weeks.  I  do  not  know 
the  history  of  this"  case,  but  judge  that  if  the  disease  were  limited  to  the 
pylorus,  and  the  patient  had  strength  sufficient  to  survive  gastrostomy, 
better  success  might  have  attended  gastro-enterostomy. 

Duodenostomy — Another  operation  which  has  been  performed  for  the 
relief  of  pyloric  stenosis  is  duodenostomy,  or  the  establishment  of  a  duodenal 
fistula  through  which  the  patient  could  be  fed.  As  far  as  I  have  been 
able  to  ascertain,  this  has  been  done  but  three  times,  all  of  which  termi- 
nated fatally,  not  so  much  however  as  the  result  of  the  operation,  as  from 
the  fact  that  it  had  been  delayed  too  long. 


Statistical  Summary  of  Cases  of  Duodenostomy. 


6 

Operator. 

Residence. 

Date. 

|  Sex. 

if; 
< 

Diagnosis. 

Result. 

Cause. 

Reference. 

1 

Langenbuch 

Berlin 

1879 

F. 

32 

Carcinoma 

Death  on 

Inanition 

Berl.  Klin.Woch. 

Sept  4 

7th  day 

1881,  p.  236. 

2 

Robertson 

Oldbam 

18S3 

? 

? 

Cicatricial 

Death  in 

? 

Brit.  Med.  Journ. 

England 

stenosis 

12  hours 

18S4,  vol.  i.  1146. 

3 

Southam 

Manchester, 

1SS4 

M 

45 

Fibrous 

Death  on 

Inanition 

Ibid. 

England 

Mr.  20 

stenosis 

3d  day 

Rydygier  reported  three  cases  of  duodenal  fistula,  all  fatal,  for  what  cause 
created,  I  do  not  know. 


1  Medical  News,  November  22,  1884,  p.  578,  also  personal  letter  to  me. 

2  Deutsche  Med.  Wochens.,  1883,  p.  319. 


364 


"Winslow,  Pyloric  Stenosis. 


[April 


In  two  of  these  cases  the  stenosis  was  found  to  be  cicatricial  in  char- 
acter, the  other  carcinomatous.  In  the  case  of  Langenbuch,  of  Berlin, 
which  was  performed  on  Sept.  4,  1879,  an  exploratory  incision  was  made 
with  the  intention  of  resecting  the  pylorus,  but  the  conditions  were  found 
to  be  too  unfavorable,  hence  the  first  portion  of  the  duodenum  was  united 
to  the  abdominal  wound  and  a  fistula  created.  The  patient  died  of  inani- 
tion. In  Southam's  case  resection  might  have  been  easily  performed,  but 
for  the  great  feebleness  of  the  patient.  His  as  well  as  Robertson's  case 
were  similar  in  character  to  those  which  have  been  so  successfully  treated 
by  Loreta,  of  Bologna,  by  digital  divulsion. 

Notwithstanding  the  failure  of  these  few  operations  to  accomplish  the 
purpose  for  which  they  were  intended,  they  prove  effectually  the  feasibility 
of  the  procedure.  In  experiments  upon  the  cadaver,  Southam  found  it 
extremely  difficult  to  reach  the  first  portion  of  the  duodenum  in  order  to 
attach  it  to  the  abdominal  walls,  but  when  the  pylorus  is  the  seat  of  dis- 
ease, the  stomach  is  usually  dragged  downwards  and  the  duodenum  is 
correspondingly  displaced,  and  in  nope  of  these  cases  was  any  difficulty 
experienced  in  attaching  the  duodenum  to  the  wound. 

In  the  cases  of  Langenbuch  and  Southam,  the  operation  was  performed 
in  two  stages.  1st.  The  duodenum  was  attached  to  the  wound  by  sutures 
extending  through  the  entire  abdominal  parietes,  and  the  serous  and  mus- 
cular tunics  of  the  gut.  2d.  After  seven  days  in  one  case  and  three  in 
the  other  the  intestine  was  incised  and  nutritive  instillations  employed. 
The  relief  came  too  late,  and  both  cases  perished  of  inanition.  No  peri- 
tonitis or  other  unfavorable  symptoms  were  encountered.  Southam  men- 
tions inveterate  ulcer  of  the  stomach  as  another  indication  for  the  perform- 
ance of  duodenostomy,  in  order  to  give  the  organ  physiological  rest,  and 
allow  healing  to  occur.  It  seems  to  me  that  this  would  be  a  doubtful, 
very  disagreeable,  and  withal  dangerous  remedy  for  simple  ulcer  of  the 
stomach,  and  what  is  probably  equally  as  good,  and  much  safer,  treatment 
by  rectal  alimentation  ought  to  be  conscientiously  tried  before  resorting 
to  any  serious  surgical  procedure.  If  after  faithfully  trying  rectal  feeding 
it  became  necessary  to  undertake  some  operation,  my  preference  would  be 
for  gastro- enterostomy. 

One  of  the  greatest  disadvantages  of  gastrostomy  is  the  irritation  and  ex- 
coriation of  the  neighboring  integuments  from  the  escape  of  the  secretions 
of  the  stomach,  equally  as  harassing  would  be  the  escape  of  the  bile  and 
other  secretions  from  a  duodenal  fistula.  In  concluding  this  short  review 
of  this  operation  it  strikes  me  that  it  is  a  procedure  which  is  likely  to  have 
but  few  repetitions,  as  divulsion  of  the  pylorus  in  non-malignant,  and 
gastro-enterostomy  in  malignant  stenosis  will  be  sufficient  for  all  cases 
which  imperatively  demand  relief. 

Digital  Divulsion  of  the  Pylorus. — This  operation  was  devised 
by  Prof.  Loreta,  of  Bologna,  for  the  relief  of  non-carcinomatous  stricture 


1885.] 


Wins  low,  Pyloric  Stenosis. 


365 


of  the  pylorus,  and  was  performed  successfully  for  the  first  time  on  Sept. 
14,  1882.  The  first  suggestion  in  regard  to  dilating  cicatricial  strictures 
of  the  pylorus  was  made  by  Richter,1  of  Breslau,  during  the  discussion  on 
resection  of  the  pylorus  at  the  11th  Congress  of  the  "  Deutsche  Geseilschaft 
fur  Chirurgie"  held  at  Berlin  on  June  2d,  1881.  He  said  :  "  But  for  non- 
carcinomatous  strictures  a  less  dangerous  operation,  the  forming  of  a 
duodenal  fistula,  through  which  bougies  can  be  used,  appears  better." 
This  sentiment  did  not  meet  with  much  approbation  from  the  surgeons 
present,  and  Billroth  immediately  expressed  his  opinion  that  "  stenosis, 
the  result  of  an  ulcer,  justified  the  operation  of  resection."  Loreta  appro- 
priated Richter's  suggestion,  but  modified  it,  so  that  as  performed  by  him- 
self the  operation  consisted  of  immediate  and  forcible  divulsion  of  the 
contracted  orifice  by  the  finger,  instead  of  the  more  tedious,  and  probably 
more  dangerous  instrumental  dilatation.  In  one  case  a  gastric  fistula  must 
be  formed  and  maintained,  whilst  in  the  other  the  incision  in  the  stomach 
is  sewed  up  and  the  wound  closed.  Casati2  says  :  "  The  merit  of  priority 
in  the  proposal  of  dilatation  in  pyloric  stenosis  belongs  to  Richter,  but  one 
must  recognize  in  the  divulsion  of  Loreta  a  substantial  modification  of  the 
operative  process."  The  Italians  hailed  this  operation  with  the  greatest 
enthusiasm.  Casati  declared  it  to  be  an  operation  which  will  make  an 
era  in  the  annals  of  the  science  and  will  place  the  name  of  Loreta  amongst 
those  of  the  greatest  and  most  illustrious  surgeons  of  the  age. 

As  far  as  I  can  ascertain  digital  divulsion  of  the  pylorus  has  been  per- 
formed six  times  with  the  following  results :  recoveries  3,  deaths  2,  doing 
well  when  heard  from  1. 


Statistical  Summary  of  Cases  of  Digital  Divulsion  of  the  Pylorus. 


© 

Operator. 

Resi- 
dence. 

Date. 

<s 
m 

1    Age.  | 

Symptoms. 

Diag- 
nosis. 

D  n  ra- 
tion of 
oper. 

Result. 

Reference. 

1 

Loreta 

Bologna 

1S82 

M 

47 

Suffering  for  20 

Stenosis 

33 

Cure 

Journ.  Am.  Med. 

Sept.  14 

years  ;  pain  and 

from 

mins. 

Assoc.,  1S83, 

Woody  vomiting. 

ulcer 

vol.  i.  p.  28. 

2 

Loreta 

Bologna 

1882 

M 

18 

Suffering  for  7 

Stenosis 

50 

Cure 

Raccoglitore  Me- 

Dec. 22 

years ;  pain, 

from 

mins. 

dico,  18S3,p.l47, 

vomiting,  and 

ulcer 

emaciation. 

S 

Giommi 

Cesena 

1883 

? 

? 

Patient  in  very 

Stenosis 

? 

De'thin 

Ibid. 

Feb.  1 

bad  condition. 

from 

12hrs. 

ulcer 

coll'pse 

4 

Loreta 

Bologna 

1883 

M 

46 

Suffered  17  years 

Stenosis 

28 

De'thin 

Ibid.,  1883,  p.  275. 

Mar.  17 

with  chronic 

from 

mins. 

36  hrs. 

gastritis,  bloody 

ulcer 

vomiting,  etc. 

5 

Loreta 

Bologna 

1883 

M 

? 

Suffered  3  years 

Stenosis 

20 

Cure  in 

L'Independente, 

July  15 

daily  vomiting, 

from 

mins. 

10  days 

Aug.  15, 1883,  p. 

gradually  starv- 

ulcer 

552. 

6 

Frattini 

Venice 

1884 

? 

? 

ing. 

1 

Stenosis 

? 

Doing 

Gazetta  degli 

June  9 

from 

well  on 

Ospitali,  June 

ulcer 

3d  day 

15,  1884,  p.  392. 

1  Deutsche  Med.  Wochens.,  1882,  p.  381. 

2  Raccoglitore  Medico,  1882,  p.  81. 
No.  CLXXVIII  April,  1885.  24 


366 


Win  slow,  Pyloric  Stenosis. 


[April 


This  does  not  profess  to  be  a  complete  record  of  all  the  digital  divulsions 
of  the  pylorus  which  have  been  performed,  but  they  are  all  that  I  have 
been  able  to  collect  from  the  literature  at  my  disposal.  I  have  strong 
reasons  for  believing  that  a  number  of  other  cases  have  been  operated  on. 

As  yet  the  operation  of  digital  divulsion  of  the  pylorus  has  not  extended 
beyond  the  land  of  its  birth,  Italy,  but  it  does  not  seem  to  have  attracted 
that  emulation  which  it  deserves. 

The  technique  of  the  operation  is  thus  described  by  Dr.  Hubert  -}  The 
incision  of  the  abdominal  walls  over  the  pyloric  extremity  of  the  stomach 
on  the  right  side,  parallel  with  the  costal  arch  for  a  distance  of  five  or  six 
inches.  The  stomach  was  thus  brought  into  the  wound  and  an  opening 
made  near  the  pylorus,  the  index  finger  was  then  introduced  into  its 
cavity  and  gradually  insinuated  into  the  pyloric  orifice,  the  index  of  the 
other  hand  was  then  entered  by  the  side  of  the  first  and  they  were  forcibly 
separated  until  a  dilatation  of  three  inches  had  been  accomplished,  and  the 
pylorus  was  felt  to  yield.  The  stomach  wound  was  united  by  the  Apolito- 
Gely  suture,  and  the  abdomen  closed  in  the  usual  manner.  The  length  of 
time  consumed  in  the  operations  of  Loreta  varied  from  20  to  50  minutes, 
the  average  of  the  four  being  32|  minutes.  The  patients  did  not  suffer 
from  profound  shocks,  and  were  able  to  take  nourishment  in  a  short  while. 

Symptoms,  etc  The  perusal  of  the  histories  of  the  cases  recorded  is 

replete  with  interest  and  information.  The  patients  had  been  suffering  for 
periods  varying  from  three  to  twenty  years  with  digestive  disturbances, 
pain  and  vomiting  of  blood,  until  they  were  reduced  to  the  very  verge  of 
starvation.  The  diagnosis  in  all  the  cases  was  cicatricial  stenosis  from 
ulcer.  It  is  somewhat  remarkable  that  so  many  cases  of  simple  stenosis  of 
the  pylorus  should  have  come  under  the  notice  of  one  man  in  such  a  short 
time,  and,  as  stated  by  Dr.  R.  P.  Harris  in  The  Medical  News  (April  21, 
1883),  is  probably  due  to  the  generally  defective  nourishment  of  the  poorer 
classes  of  Italians. 

Results  The  result  of  these  cases  is  very  gratifying;  of  six  cases 

operated  on  three  were  entirely  relieved  of  all  distressing  symptoms,  and 
were  able  to  eat  and  digest  ordinary  food  almost  at  once.  The  first  pa- 
tient upon  whom  Loreta  operated  gained  forty-six  pounds  in  one  month  ; 
and  that  the  results  gained  are  fairly  lasting  is  authenticated  by  Dr.  Guido 
Pedrazzoli2  of  the  Bologna  Hospital,  who,  writing  concerning  the  first  two 
cases  nearly  a  year  subsequently,  says  :  "  The  cases  of  recovery  are  per- 
fect. Two  cases  have  proved  fatal,  that  of  Dr.  Giommi  from  collapse  in 
twelve  hours,  the  patient  having  been  in  a  wretched  condition  previously. 
Loreta's  3d  case  died  in  thirty-six  hours,  probably  from  exhaustion,  as  he 
rallied  well  after  the  operation.  Frattini's  case  was  doing  well  when  re- 
ported three  days  after  the  operation."  We  have  thus,  of  five  cases  in  which 

1  Jour.  Med.  Chir.  Pharmacol.,  Bruxelles,  April,  1883.  See  translation  in  Jour. 
Am.  Med.  Assoc.,  vol.  i.  p.  23,  July  14,  1883. 

2  Lancet,  1883,  vol.  ii.  p.  213. 


1885.J 


Win  slow,  Pyloric  Stenosis. 


367 


the  result  is  known,  3  recoveries  and  2  deaths,  or  60  per  cent,  of  suc- 
cesses. Reasoning  from  analogy,  it  appears  most  rational  to  attempt  the 
dilatation  of  these  connective-tissue  strictures.  Who  excises  the  rectum 
or  urethra  for  a  non-malignant  stricture  ?  Of  course  the  matter  is  entirely 
different  with  regard  to  carcinoma  of  the  pylorus,  in  which  event  forcible 
dilatation  would  probably  lead  to  rupture  of  the  diseased  walls,  hemorrhage 
or  other  disastrous  consequences.  The  short  duration  of  the  operation  of 
digital  divulsion,  the  slight  shock,  the  immediate  and  most  astonishing 
improvement  which  takes  place  in  those  who  recover,  and  the  apparent 
permanence  of  the  cure,  notwithstanding  the  opinions  which  have  been 
expressed  that  recontraction  would  occur,  attest  the  excellence  of  this 
operation,  and  inevitably  leads  me  to  the  conclusion  that  the  medical  pro- 
fession is  immensely  indebted  to  Prof.  Loreta  for  the  development  of  this 
procedure,  which  as  yet  has  not  received  the  attention  which  it  deserves. 

Casati1  says  digital  divulsion  presents  three  great  advantages  over  re- 
section:  1st.  Its  execution  is  easier.  2d.  It  is  less  dangerous.  3d.  The 
conservation  of  a  portion  of  the  stomach  which  has  certainly  some  office 
in  the  function  of  digestion  which  would  be  sacrificed  by  resection.  The 
statistics  amply  prove  the  first  of  these  propositions.  The  average  dura- 
tion of  the  four  operations  of  divulsion  was  32|  minutes  ;  the  cases  in 
which  excision  was  performed  for  ulcer  required  5,  2,  and  1 J  hours 
respectively  ;  the  length  of  the  other  cases  not  being  known  to  me.  That 
it  is  less  dangerous  is  probable,  as  six  excisions  of  the  pylorus  were  fol- 
lowed by  50  per  cent,  of  recoveries,  six  digital  divulsions,  if  we  include 
as  a  failure  the  case  which  was  doing  well  on  the  third  day  when  reported, 
by  50  per  cent,  of  recoveries,  or,  if  we  exclude  this,  the  average  of  recov- 
eries in  the  five  cases  in  which  the  termination  is  known  is  60  per  cent. 
The  last  proposition  quoted  scarcely  holds  a  very  great  value,  as  the  re- 
sult of  the  extirpation  of  almost  the  whole  stomach  of  a  dog  by  Kaiser  was 
perfect  digestion  and  absolute  increase  in  weight,  so  that  when  the  animal 
was  killed  for  experimental  purposes  in  1884,2  eight  years  subsequent  to 
the  mutilation  of  his  stomach,  he  was  in  much  better  condition  than  pre- 
vious to  the  operation.  Further,  those  patients  who  have  recovered  from 
pylorectomy  have  enjoyed  good  digestion,  and  have  not  appeared  to  suffer 
from  the  loss  of  the  excised  portion.3 

Conclusions. — As  in  croup  stenosis  of  the  air-passages  is  the  indi- 
cation for  tracheotomy,  so  stenosis  of  the  pylorus  is  the  indication  for  any 
operation  upon  this  portion  of  the  stomach  in  cancerous  affections.  If  the 
patient  simply  suffers  pain  or  distress,  let  him  have  opium  freely  enough 
to  overcome  it.    There  is  no  probability  that  an  operation  would  effect  a 

1  Raccoglitore  Medico,  1883,  p.  81. 

2  Maurer,  Arkiv  fur  Klin.  Chirurg.,  1884,  Bd.  xxx.  Heft  1. 

3  According  to  Revue  Medicale,  Prof.  Loreta  has  practised  digital  divulsion  of  the 
pylorus  five  times  with  success.  He  says  :  "  Kesection  of  the  pylorus  for  simple  and 
cicatricial  stenosis  should  he  replaced  by  digital  dilatation." — Med.  News,  Feb.  28, 1885. 


368 


Win  slow,  Pyloric  Stenosis. 


[April 


permanent  cure,  and  the  mortality  is  too  great  to  perform  it  for  a  slight 
temporary  benefit.    Let  such  patients  have  anodynes. 

When  stenosis  is  present,  as  is  indicated  by  obstinate  vomiting,  dilata- 
tion of  the  stomach,  scanty  stools,  and  marked  emaciation,  something  must 
be  done,  or  the  patient  will  die  of  starvation.  If  the  patient  is  young, 
with  a  considerable  degree  of  strength,  and  the  tumor  circumscribed  and 
not  adherent  to  the  surrounding  organs,  a  resection  may  be  performed, 
with  however  only  a  prospect  of  saving  one-half  of  those  submitted  to  it. 

When,  however,  the  patient  is  feeble,  or  aged,  and  there  are  adhesions 
to  the  pancreas  or  infiltration  of  the  neighboring  glands,  resection  ought 
not  to  be  performed.  In  such  cases  gastroenterostomy  would  effect  all 
that  could  be  expected  from  resection,  with  less  immediate  danger,  and 
would  be  much  more  satisfactory  than  duodenostomy,  or  gastrostomy  with 
a  tube  pushed  through  the  stenosed  orifice.  In  fact  I  do  not  think  I 
would  be  far  wrong  in  assuming  that  better  results  would  follow  gastro- 
enterostomy in  all  cases,  though  I  hold  it  to  be  justifiable  to  perform  pylo- 
rectomy  in  those  very  exceptional  cases  in  which  there  are  no  adhesions 
or  extended  glandular  involvement,  and  the  strength  of  the  patient  is  still 
fairly  good. 

For  stenosis  due  to  ulcer  or  to  corrosive  liquids  which  have  been 
swallowed,  whilst  resection  if  successful  is  probably  permanent  in  its 
effects,  I  think  the  results  obtained  by  Loreta  from  digital  divulsion  demand 
our  most  earnest  attention.  In  my  opinion  divulsion  should  be  substituted 
for  resection  in  all  cases  of  simple  cicatricial  stenosis  which  are  amenable 
to  this  treatment.  I  can  readily  imagine  a  condition  in  which  the  de- 
velopment of  cicatricial  tissue  has  gone  to  such  an  extent  that  digital  di- 
vulsion would  be  impossible ;  in  such  cases  pylorectomy  remains,  or  what 
would  be  still  better  in  some  cases  gastroenterostomy. 

Summary — 1st.  In  cancer  of  stomach  not  producing  stenosis,  give  ano- 
dynes in  quantities  sufficient  to  relieve  distress,  and  do  not  operate. 

2d.  Pylorectomy  for  carcinoma  is  followed  by  76  per  cent,  mortality; 
hence  it  should  only  be  very  exceptionally  performed — in  those  cases  where, 
with  marked  stenosis,  the  pylorus  is  not  adherent  to  the  neighboring  or- 
gans, and  the  patient  is  young  and  fairly  strong. 

3d.  In  other  cases  of  carcinomatous  stenosis,  as  only  very  temporary 
benefit  can  be  obtained,  perform  gastro-enterostomy. 

4th.  In  cicatricial  stenosis  perform  digital  divulsion,  but,  if  this  is  im- 
possible, owing  to  great  thickening  of  the  walls,  resection  in  those  who  are 
well  nourished,  and  gastro-enterostomy  in  the  debilitated  will  both  be  fol- 
lowed by  good  results. 

5th.  In  the  opinion  of  the  writer  hemorrhage  or  perforation  from  ulcer 
or  other  cause  than  stenosis  does  not  present  indications  for  pylorectomy. 

6th.  Duodenostomy,  gastrostomy  for  the  passage  of  a  tube,  and  complete 
gastrectomy  should  all  be  replaced  by  gastro-enterostomy. 
201  W.  Biddle  St.,  Baltimore,  Md.,  Feb  9, 1885. 


1885.] 


Spear,  Partial  Pylorectomy. 


369 


Article  III. 

Report  of  a  Case  of  Partial  Pylorectomy.     By  J.  M.  Spear,  M.D., 

of  Cumberland,  Md. 

S.  P.  W.,  aged  40,  blacksmith,  without  known  hereditary  predisposi- 
tions, suffered  from  symptoms  of  chronic  gastritis  for  four  years  previous 
to  August,  1880,  at  which  time  the  morbid  condition  culminated  in  gastric 
ulcer,  with  such  volent  symptoms,  as  pain,  hsematemesis,  etc.,  that  I  inter- 
dicted stomachic  ingestion,  substituting  therefor  rectal  alimentation.  This 
regime  was  inviolably  adhered  to  for  five  weeks,  after  which  time  food 
was  sparingly  and  guardedly  allowed  by  the  stomach  without  a  recurrence 
of  his  former  dyspeptic  symptoms.  In  fact,  his  stomach  seemed  perfectly 
restored;  he  gained  flesh  rapidly  ^running  up  from  120  to  166  pounds  in 
a  short  time),  and  remaining  in  apparent  perfect  health  for  about  two 
years.  After  this  length  of  time  he  would  come  to  me  only  occasionally 
with  symptoms  of  gastric  catarrh,  lasting  generally  only  a  few  days  ; 
until  the  latter  part  of  1883  and  the  beginning  and  spring  of  1884,  when 
his  attacks  became  more  frequent  and  more  prolonged,  and  his  symptoms 
more  obstinate,  and  occasionally  attended  with  vomiting. 

In  the  spring  of  1884  he  abandoned  his  trade  and  accepted  the  appoint- 
ment of  street  supervisor ;  his  condition  through  the  summer  became 
more  grave,  and  as  fall  approached  his  gastric  trouble  became  constant ; 
he  was  never  entirely  free  from  dyspeptic  symptoms  for  more  than  a  few 
hours  at  a  time,  and  vomiting  was  habitual.  Nothing  that  he  could 
eat  agreed  with  him  ;  the  yelk  of  hard-boiled  eggs  being  most  accept- 
able, upon  which  he  largely  subsisted.  He  could,  however,  eat  a  full 
meal  and  feel  tolerably  comfortable  for  a  few  hours ;  then  sour  eructations 
would  come  on,  with  the  emission  of  large  quantities  of  gas,  attended  with, 
perhaps,  headache,  feverishness,  and  a  general  uneasiness,  to  be  relieved 
only  by  vomiting.  His  appetite  remained  good  throughout  his  sickness  ; 
he  had,  in  the  latter  part  of  his  sickness,  no  actual  pain,  and  seldom  any 
tenderness  ;  the  bowels  never  moved  spontaneously. 

In  November  his  vomiting  became  systematic.  At  intervals  of  two  or 
three  days,  usually  in  the  night,  he  would  vomit  large  quantities  of  ingesta 
(a  gallon  or  more)  without  nausea,  the  vomiting  being  generally  excited 
by  some  movement  in  bed,  and  often  beginning  while  asleep. 

At  this  time  I  could  run  a  gallon  of  wrater  into  the  stomach  without 
his  experiencing  any  feeling  of  distension,  or  discomfort ;  it  immedi- 
ately returned  with  the  residual  contents,  often  to  the  amount  of  ten  or 
twelve  pints.  The  vomited  liquids  often  had  a  yellowish  tinge,  but  never 
showed  any  reaction  of  bile,  and  bismuth  by  the  mouth  failed  to  color  the 
stools,  showing  that  the  stenosis,  which  was  believed  to  be  cicatricial, 
amounted  practically  to  occlusion.  He  had  now  become  very  much  ema- 
ciated, and  so  weak  that  he  no  longer  left  his  bed.  Food  per  orem  caused 
him  so  much  distress,  and  afforded  him  so  little  nourishment,  that  it  was  on 
the  14th  of  December  withheld,  and  nutritive  enemata,  consisting  princi- 
pally of  beef  peptonoids,  substituted.  With  these  his  dyspeptic  symptoms 
ceased  entirely,  as  did  his  vomiting,  except  when  a  trial  was  made  of  the 
stomach's  tolerance,  an  encroachment  invariably  resented.  For  three 
weeks  he  felt  quite  comfortable  under  this  treatment,  complaining  of  noth- 


370 


Spear,  Partial  Pylorectomy. 


[April 


ing  but  hunger,  his  strength  keeping  up  remarkably  well,  considering  his 
reduced  condition. 

On  January  2d  I  asked  Drs.  C.  H.  Ohr,  D.  P.  Welfley,  and  W.  W. 
Wiley  to  see  the  case  with  me  to  consider  the  advisability  of  operative 
interference.  They  all  concurred  in  the  opinion  that  an  operation  was  indi- 
cated, with,  at  that  time,  a  fair  prospect  of  success.  In  the  week  ensuing, 
while  the  patient  considered  the  matter,  he  weakened  quite  rapidly,  so  that 
his  condition  on  the  9th,  when  again  seen  by  the  above-named  physi- 
cians, was  found  far  less  favorable  than  at  the  previous  consultation  ;  but, 
still  considering  the  operation  justifiable,  we  determined  to  give  him  the 
benefit  of  the  chance. 

Accordingly  at  1 1  o'clock,  January  10,  assisted  by  Drs.  Ohr,  Wiley,  Welfley, 
Doerner,  and  McClintock,  I  undertook  the  operation,  which  was  a  modifi- 
cation of  Billroth's,  and  required  an  hour  and  a  half  in  its  performance. 
The  anaesthetic  used  was  Barr's  Mixture,  of  which  four  and  a  half  ounces 
were  sufficient  to  preserve  complete  anaesthesia  during  the  whole  time  occu- 
pied by  the  operation.  The  temperature  of  the  room  was  kept  between 
80°  and  90°  F.  The  sponges,  cloths,  instruments,  and  hands  of  assist- 
ants were  thoroughly  disinfected,  and  strict  cleanliness  enforced.  The 
water  used  to  moisten  sponges  and  cover  instruments  was  a  two  per  cent, 
solution  of  carbolic  acid  kept  warm  by  being  frequently  renewed.  The 
ligatures  and  sutures  were  animal — very  fine  silk — sublimatized  in  a  solu- 
tion of  1-2000  and  waxed  with  carbolized  wax  1-20.  Small  cambric 
needles  were  used.  The  extremities  were  wrapt  in  blankets,  and  bottles 
of  hot  water  held  in  readiness.  Shortly  before  the  operation  he  was  given 
a  pint  of  peptonized  milk  and  three  ounces  of  whiskey  per  rectum.  Pulse 
of  patient  80°,  temperature  normal,  no  palpable  tumor  or  evidence  of  dis- 
ease in  any  other  part  than  the  stomach. 

The  surface  of  the  abdomen  was  thoroughly  washed  with  soap  and  warm 
water  and  afterwards  with  the  carbolic  solution.  The  stomach  was  washed 
out  the  day  preceding  with  a  solution  of  boracic  acid,  but  as  the  effort  had 
weakened  him  considerably,  it  was  deemed  imprudent  to  undertake  it  on 
the  day  of  the  operation. 

An  incision  two  inches  long  was  made  to  the  right  of  the  median  line 
midway  between  the  umbilicus  and  costal  margin,  to  which  latter  it  was 
parallel,  hemorrhage  being  arrested  as  the  dissection  proceeded.  With 
two  fingers  the  abdomen  was  explored,  the  pylorus  located  and  found  free 
from  adhesions,  and  the  omenta  free  from  enlarged  or  indurated  glands. 
A  sponge  was  next  introduced  into  the  abdomen,  the  scissors  applied  over 
it,  and  the  incision  prolonged  from,  or  a  little  to  the  left  of,  the  median  line, 
four  and  a  half  inches  in  the  direction  already  indicated.  The  pylorus 
was  lifted  into  view,  appearing  quite  natural  externally  as  regards  size, 
color,  etc.,  but  showing  marks  of  cicatrization  on  the  superior  part,  and 
extending  about  two  inches  along  the  lesser  curvature  of  the  stomach,  to 
which -extent  the  wall  felt  very  much  thickened  and  indurated.  The  point 
of  the  little  finger,  invaginating  the  thin  wall  of  the  stomach  above,  or  the 
duodenum  below,  failed  to  enter  the  constriction,  but  two  fingers  used 
conjointly  in  this  way  located  the  most  constricted  part  very  exactly. 

The  next  step  was  to  separate  the  greater  and  lesser  omenta,  which  was 
done  mainly  by  the  fingers  and  forceps,  with  the  use  of  only  two  double 
ligatures  to  masses  of  the  omentum,  in  one  of  which  was  divided  the 
gastro-epiploica  dextra  artery.  The  isolated  part  was  then  drawn  through 
the  abdominal  incision,  and  a  folded  carbolized  linen  cloth  placed  under 


1885.] 


Spear,  Partial  Pylorectomy. 


371 


it,  securing  the  contents  of  the  abdomen,  affording  a  platform  upon  which 
to  work,  as  well  as  furnishing  an  absorbent  for  the  blood.  An  incision 
was  begun  at  the  lesser  curvature  of  the  stomach,  a  short  distance  above 
the  pylorus,  and  carried  obliquely  towards  the  latter  through  the  thickened 
wall  into  the  cavity.  The  wall  was  found  to  be  not  less  than  three-fourths 
of  an  inch  thick  ;  the  thickening  being  limited  to  the  upper  part  of  the 
pylorus  and  lesser  curvature  of  the  stomach,  terminating  abruptly  with  the 
pyloric  sphincter.  The  stomach  and  duodenum  were  both  found  quite 
empty.  The  scissors  were  then  applied  to  the  duodenal  side  of  the  con- 
stricting tumor,  circumscribing  it,  and  the  incision  carried  into  the  first 
incision,  terminating  at  its  lower  extremity.  It  was  found  that  while  we 
had  a  large  entrance  into  the  duodenum,  not  unlike  the  case  reported  by 
Van  Kleef,  the  orifice  into  the  stomach  would  not  admit  the  finger,  necessi- 
tating the  excision  of  more  of  the  thickened  wall  in  order  to  get  sufficient 
calibre,  as  well  as  more  pliable  material  for  suturing. 

We  had  now  removed  a  triangular-shaped  piece  from  the  doubled  vis- 
cus,  the  lower  angle  reaching  beyond  the  centre,  leaving  the  most  depend- 
ent point  of  the  pylorus  intact.  In  separating  the  omenta  and  making  the 
above  incisions,  the  hemorrhage,  which  altogether, was  quite  insignificant, 
as  only  eight  arteries  required  ligating,  was  arrested  at  each  step. 

The  parts  were  coaptated,  and  secured  by  three  "  occlusion"  and  eleven 
"  ring"  Lambert  sutures,  the  abdominal  cavity  was  sponged  dry,  the  ex- 
ternal incision  closed  by  two  quilled  and  eight  interrupted  sutures,  and 
dressed  with  an  antiseptic  compress  and  bandage. 

During  the  operation  several  hypodermics  of  whiskey  were  given,  and 
immediately  after  the  operation  a  hypodermic  of  morphia  and  atropia. 
The  patient  rallied  well  from  the  effects  of  the  anaesthetic,  regaining  con- 
sciousness in  a  few  minutes,  and  expressed  himself  as  being  comfortable. 
Pulse  at  this  time  120,  and  of  fair  strength.  He  was  given  an  enema  of 
peptonized  beef  and  whiskey.  He  apparently  did  well  for  an  hour  and  a 
half  after  the  operation,  after  which  time  his  pulse  became  frequent  and 
weak,  and  in  spite  of  our  efforts  to  sustain  him  with  cardiac  stimulants 
and  tonics  hypodermically,  his  heart  failed  him  two  hours  and  a  half  after 
the  operation.    No  autopsy. 

Competent  microscopists  examined  the  specimen,  and  found  nothing 
indicative  of  malignancy. 

His  becoming  rapidly  worse  after  changing  his  occupation  I  attribute  to 
the  want  of  the  accustomed  succussions  and  little  concussions  received  in 
the  bent-over  position,  during  the  act  of  shoeing  horses  (at  which  he  was 
occupied  a  greater  part  of  his  time),  which  thus  acted  as  an  auxiliary 
means  of  emptying  the  stomach. 

In  looking  back  upon  the  case,  I  now,  as  I  did  then,  regard  it  as  a  case 
in  every  way  eminently  proper  for  the  operation,  if  performed  in  time;  but 
as  it  was,  it  must  be  regarded  as  a  "  too  late"  operation. 


372 


Hun,  Alcoholic  Paralysis. 


[April 


Article  IV. 

Alcoholic  Paralysis.    By  Henry  Hun,  M.D.,  Lecturer  on  Nervous 
Diseases  in  the  Albany  Medical  College. 

The  immediate  and  transient  effects  of  an  excessive  quantity  of  alcohol 
upon  the  human  nervous  system,  whether  they  are  manifested  in  the  form 
of  drunkenness,  or  of  delirium  tremens,  or  of  an  acute  attack  of  insanity, 
are  well  known.  Scarcely  less  evident  are  the  effects  produced  upon  the 
nervous  system  by  a  less  excessive,  but  a  more  prolonged  abuse  of  alcoholic 
drinks.  These  effects  may  be  manifested  either  in  a  general  failure  of 
physical  and  mental  power,  or  in  a  form  of  disease  closely  resembling 
progressive  paralytic  dementia,  or  in  various  forms  of  chronic  insanity,  or 
in  epilepsy,  or  in  neuralgia,  or  in  paralysis.  In  the  acute  form  of  alcoholic 
poisoning,  no  change  in  the  structure  of  the  nervous  system  has  been 
found,  except  that  the  meninges  in  common  with  the  internal  organs  and 
the  mucous  membranes  are  the  seat  of  a  very  decided  injection  and  of  a 
slight  exudation.  In  the  chronic  form  of  alcoholism,  a  number  of  patho- 
logical changes  have  been  discovered  in  the  nervous  system,  which,  how- 
ever, vary  greatly  in  different  cases.  The  pathological  conditions  most 
commonly  found  are,  pachymeningitis  interna  hemorrhagica,  thickening 
and  opacity  of  the  pia  mater,  serous  exudation  in  the  sub-arachnoid  space, 
dryness  and  toughness  of  the  cerebral  substance,  atrophy  of  the  cerebral 
convolutions,  fatty  degeneration  of  the  nerve-cells,1  and  degenerative 
changes  in  the  peripheral  nerves.2 

Of  late  years  the  paralysis  which  results  from  the  abuse  of  alcohol  has 
been  accurately  described  by  numerous  observers,  and  the  attempt  has  been 
made  to  discover  the  lesion  of  the  nervous  system  which  is  associated 
with  this  form  of  paralysis.  The  two  cases  here  reported  seem  to  be 
typical  examples  of  this  disease,  and  may  contribute  somewhat  to  a  better 
understanding  of  it. 

Case  I  A  male,  set.  28,  single,  entered  St.  Peter's  Hospital  September 

13,  1884,  and  gave  the  following  history  : — 

Family  history  good.  Patient  has  always  worked  hard,  and  has  enjoyed 
good  health  until  a  year  ago.  Has  never  had  any  venereal  disease,  but  has 
always  been  a  hard  drinker,  although  he  has  never  had  delirium  tremens. 
During  many  years  he  has  drunk  steadily  and  excessively,  and  during  the 
year  previous  to  this  sickness  he  has  drunk  more  than  half  a  pint  of  undi- 
luted bad  whiskey  daily.  He  had  no  settled  home,  but  slept  about  wherever 
he  could  find  a  place.  Last  winter  he  "  caught  cold,"  and  on  endeavoring 
to  get  out  of  bed  the  next  morning  he  could  not  do  so  on  account  of 
general  weakness,  pains  in  legs  and  arms,  and  inability  to  walk.    He  was 

1  Wilks,  Journal  of  Medical  Sciences,  1864. 

2  Dejerine,  Archiv.  de  physiol.  norm,  et  Pathol.,  1884,  No.  2,  p.  231.  Lancereaux, 
Gazette  Hebdom.,  1881,  Nos.  45  and  118. 


1885.] 


Hun,  Alcoholic  Paralysis. 


373 


obliged  to  stay  in  bed  for  a  week,  during  which  period  there  were  a  numb- 
ness and  tingling  in  his  feet  and  legs.  On  getting  out  of  bed,  and  on  en- 
deavoring to  walk,  he  was  obliged  to  run  forward  to  prevent  himself  from 
falling.  He  continued  in  the  same  condition  for  about  two  months,  during 
which  time  improvement  slowly  continued,  and  after  a  time  he  could 
walk  about  as  well  as  ever.  About  a  month  ago,  the  patient  began  to 
feel  the  disease  returning,  and  in  the  course  of  a  few  days  the  same 
symptoms  that  he  had  last  winter  came  on  again,  so  that  he  was  unable  to 
walk.  From  this  time  until  he  entered  the  hospital  he  suffered  from  pain, 
numbness,  and  tingling  sensations  in  his  legs  and  arms  on  both  sides,  and 
from  great  loss  of  strength  in  his  legs,  and  in  a  less  degree  in  his  arms. 
He  also  was  troubled  by  frequent  micturition,  and  by  a  sensation  of  sore- 
ness over  the  abdomen,  but  no  girdle  sensation.  Appetite  poor,  and  fre- 
quent vomiting. 

An  examination  at  the  <time  of  entrance  gave  the  following  result : 
Patient  is  of  strong  frame,  and  well  nourished.  He  seems  to  be  somewhat 
under  the  effects  of  liquor ;  he  talks  and  acts  in  a  foolish  manner,  and  is 
tremulous  ;  his  stomach  is  irritable ;  the  end  of  his  nose  is  much  enlarged 
and  congested,  and  an  acne  eruption  covers  his  face.  Slight  paresis  of  left 
side  of  face,  but  not  of  tongue  nor  of  ocular  muscles.  Pupils  equal,  and 
react  sluggishly  to  light  and  to  efforts  of  accommodation.  No  absolute 
paralysis,  but  general  paresis  of  muscles,  of  arms,  and  hands.  Grasp  of 
hands  registered  with  Mathieu's  dynamometer  is,  left  45,  right  75. 
Patient  cannot  perfectly  extend  the  last  two  fingers  of  each  hand.  Decided 
tremor  of  hands  during  voluntary  movements.  Considerable  degree  of 
ataxia  in  movements  of  left  hand,  a  somewhat  less  degree  of  ataxia  in 
movements  of  right  hand.  Patient  has  not  the  violent  ataxic  movements 
of  locomotor  ataxia,  but  rather  the  tremulous  uncertain  movements  of  the 
drunkard.  No  decided  atrophy  of  muscles  of  arms.  Sensibility  to  tactile 
impressions  over  hands,  arms,  and  legs  normal,  except  for  small  patches 
of  anaesthesia  to  slight  tactile  impressions  over  feet.  Decided  hyperes- 
thesia of  skin,  and  great  tenderness  of  muscles  on  pressure.  No  decided 
atrophy  of  muscles  of  legs.  Patient  walks  with  great  difficulty.  In  walk- 
ing he  flexes  his  thigh  strongly  on  his  body,  and  then  brings  his  foot  down 
with  a  stamp  in  the  manner  described  by  Westphal.1  His  movements  are 
very  rapid  and  uncertain,  and  he  constantly  appears  to  be  just  on  the  point 
of  falling.  His  walk  exhibits  a  mixture  of  weakness  and  ataxia.  Patient 
cannot  stand  with  his  feet  close  together,  unless  he  is  given  some  little 
support.  When  slightly  supported  he  apparently  stands  as  well  when  his 
eyes  are  shut  as  when  they  are  open,  although  he  says  that  he  feels  more 
dizzy  in  the  former  case.  When  he  attempts  to  stand  his  whole  body  is 
thrown  into  a  tremor.  When  in  bed  he  can  move  legs  freely  in  all  direc- 
tions, and  such  movements  show  a  slight  degree  of  ataxia.  Plantar,  cre- 
masteric, and  umbilical  reflexes  normal ;  no  patellar  reflex  ;  no  ankle 
clonus  ;  no  paradoxical  contraction  ;  no  rigidity,  nor  deformity  of  spine  ; 
no  tenderness  over  spinous  processes  ;  slight  tenderness  in  lumbar  region 
on  each  side  of  the  spinous  processes  over  the  muscle.  Abdominal  and 
thoracic  examination  negative,  except  that  a  short  faint  systolic  murmur 
is  heard  over  aortic  valves  and  in  subclavian  arteries.  No  enlargement  of 
the  area  of  cardiac  dulness.  R.  Blisters  along  spinous  processes.  R.  Pot. 
iodide  grs.  xv,  t.  i.  d. 


i  Charite  Annalen,  iv.  Jahrg.  1879,  p.  395. 


374 


Hun,  Alcoholic  Paralysis. 


[April 


Oct.  7.  Patient  has  slowly  grown  worse.  The  legs  are  very  weak  in 
all  their  movements,  and  exhibit  a  decided  degree  of  ataxia.  Small 
patches  of  anesthesia  to  tactile  impressions  scattered  not  only  over  feet,  but 
also  over  legs.  Sensibility  to  painful  and  thermic  impressions  normal ; 
muscles  painful  on  pressure;  can  neither  walk  nor  stand.  Patellar  reflex 
absent.  Plantar  reflex  exaggerated,  and  cutaneous  reflexes  of  any  part  of 
skin  of  legs  greatly  increased,  which  seems  to  be  due  to  a  hyperesthesia 
of  skin  of  legs  ;  cremasteric  reflex  normal;  umbilical  reflex  slight;  pupil 
reflex  normal.  Slight  degree  of  ataxia  of  hands.  Grasp  of  right  hand 
equals  60  as  registered  by  Mathieu's  dynamometer.  No  tenderness  along 
back.  Slight  paresis  of  left  side  of  face,  but  this  is  less  than  on  entrance. 
The  congestion  of  the  nose  is  very  much  less,  and  there  is  only  a  slight 
degree  of  tremor  remaining.  Patient  sometimes  loses  his  legs  in  bed,  so 
that  he  cannot  tell  in  what  position  they  are.  R.  Pot.  iodide  grs. 
xxv,  t.  i.  d. 

14th.  The  large  doses  of  iodide  cause  much  discomfort,  producing  an 
intense  coryza,  and  a  severe  conjunctivitis.  Paresis  of  left  side  of  face 
has  almost  entirely  disappeared.  Muscles  of  legs  flabby  and  atrophied. 
Muscles  of  legs  decidedly  tender  on  pressure.  No  pain  on  passive  motion. 
Patient  is  quite  unable  to  walk.  Circumference  of  thigh  two  inches,  above 
knee  is  12  inches.    Greatest  circumference  of  calf  of  leg  11|  inches. 

Nov.  10.  No  decided  change  ;  patient  is  rather  stronger.  The  coryza 
and  conjunctivitis  disappeared  after  about  ten  days,  but  he  now  has  an 
extensive  eruption  of  acne.  Omit  the  iodide.  R.  Faradic  current  to 
arms  and  legs.    R.  Strychnine  sulph.  gr.  gL,  t.  i.  d. 

Dec.  1.  Decidedly  better.    Can  walk  a  little  once  more. 

15th.  Patient  is  decidedly  better.  Can  walk  and  stand  for  a  short  time. 
His  walk  is  still  very  unsteady,  and  stamping  as  at  time  of  entrance.  Can 
button  his  clothes  once  more,  which  for  a  long  time  he  was  unable  to  do. 
No  facial  paresis.  Ataxic  movements  are  very  slight.  Grasp  of  hands 
strong.  Sensibility  to  tactile  impressions  over  both  arms  and  legs  normal. 
Localization  of  tactile  impressions  normal,  except  as  regards  the  toes ;  the 
patient  not  being  able  to  tell  always  which  toe  is  touched.  Sensibility  to 
painful  and  thermic  impressions  normal.  No  retardation  of  conduction  of 
painful  nor  tactile  impressions.  Patellar  reflex  and  ankle  clonus  absent. 
Cutaneous  reflex  exaggerated.  Circumference  of  thigh  three  inches  above 
knee-joint,  right  12^  inches,  left  12  inches.  Greatest  circumference  of 
calf  of  leg,  right  11  inches,  left  10|  inches. 

Electric  examination  made  with  the  Macintosh  combined  battery. 

The  positive  pole  on  upper  part  of  sternum,  the  negative  pole  on  point 
to  be  tested. 

Faradic  current. 

Peroneus  nerve,  right,  cylinder  withdrawn  If  inches. 

"  "  left,      '    "  "       If  " 

Tibialis  anticus  muscle,    left,         "  u       3  " 

but  the  contraction  becomes  much  stronger  as  the  electrode  is  slowly 
moved  outwards  towards  the  head  of  the  fibula  and  the  peroneus  nerve. 
No  contraction  can  be  obtained  from  the  right  tibialis  anticus  muscle 
when  the  electrode  is  over  the  muscle  itself,  but  when  the  electrode  is  held 
midway  between  the  motor  point  for  the  muscle  and  the  head  of  the  fibula 
a  sluggish  contraction  is  obtained  when  the  cylinder  is  withdrawn 
inches  ;  when  the  cylinder  is  withdrawn  more  the  contraction  of  the  mus- 
cle loses  its  sluggish  character  and  appears  normal.    A  sluggish  contraction 


1885.] 


Hun,  Alcoholic  Paralysi 


375 


of  vastus  internus  muscle  on  both  sides  when  cylinder  is  withdrawn  2f 
inches. 

Nerves  of  arms  and  muscles  on  anterior  surface  of  forearm  respond 
when  cylinder  is  entirely  in.  Extensor  muscles  of  forearm  and  muscles 
of  base  of  thumb  respond,  quick  contraction,  when  cylinder  is  withdrawn  1^ 
inches. 

Galvanic  current  measured  in  milliamperes  by  a  Gaiffe  galvanometer. 

Right  peroneus  nerve,  negative  closing,  5-^  ;  positive  closing,  13 

Left         "         "  "  "     5j       "  "  12 

Right  tibialis  anticus  muscle,       "  "    14         "  "  11 

Left         "         "       "  "  "    10         "  "  8J 

Right  vastus  internus,  "  "    20^       "  "  17 

The  extensor  longus  muscle  gave  no  response  to  currents  even  stronger 
than  those  given  above. 

29^/?.  Is  up  and  out  of  bed ;  can  walk  easily,  though  rather  awkwardly 
and  unsteadily.  Can  stand  with  feet  together  and  eyes  shut  without 
wavering,  although  he  complains  then  of  feeling  a  little  dizzy.  Very 
slight  tenderness  of  muscles  still  remains.  Grasp  of  left  hand  90,  right 
hand  100,  as  registered  with  Mathieu's  dynamometer.  A  careful  oph- 
thalmoscopic examination  revealed  nothing  abnormal. 

Jan.  26,  1885.  Galvanic  current  measured  in  milliamperes  by  a  Gaiffe 
galvanometer. 

Right  peroneus  nerve,  negative  closing,  6^;  positive  closing,  12 

Left    '     "         "  "  "     7         "  "  13 

"     opening,  20 

Right  tibialis  anticus  muscle,       "  "    15         "      closing,  11 

Left         "         "       "  "  "    13         "  "  18 

Faradic  current. 

All  the  muscles  and  nerves  of  arms  and  thumb  respond  readily  when 
the  cylinder  is  entirely  in  ;  the  muscles  of  the  right  arm  responding  more 
actively  than  those  of  the  left. 

Peroneus  nerve,  left,  cylinder  fully  in  ;         right,  cylinder  withdrawn  1  inch. 

Tibialis  anticus  muscle,  left,    "  withdrawn  2  inch ;  right,       "  "        3%  " 

Extensor  longus  muscle,  left,    "  "        3>£  "    right,       "  "        Zy2  " 

Vastus  internus  muscle,  left,    "         "       1%  "    right,       "  "        1%  {<1 

Patient  can  now  walk  without  difficulty  ;  can  stand  on  either  leg  alone, 
and  feels  strong.  Grasp  of  hands  measured  with  Mathieu's  dynamometer 
is,  right  115,  left  100.  There  is  no  ataxia.  Patellar  reflex  present  in 
both  legs  ;  plantar  reflexes  increased  ;  cremasteric  and  umbilical  reflexes 
normal.  No  hyperesthesia  of  skin  of  legs,  nor  tenderness  on  pressure  over 
the  muscles.  Sensibility  to  tactile,  painful,  and  thermic  impressions  nor- 
mal.   Slight  failure  of  localization  on  toes.    No  fibrillary  contraction  of 


1  In  making  the  electrical  examinations  in  this  and  the  following  case  the  18  cell 
combined  Macintosh  battery  was  employed.  A  large  sponge  electrode  was  placed 
over  the  upper  part  of  the  sternum,  and  a  small  electrode  (a  metallic  knob  y2  inch  in 
diameter  and  covered  with  a  sponge)  was  placed  over  the  motor  point  to  be  tested. 
The  strength  of  the  faradic  current  required  to  produce  a  minimal  contraction  was 
measured  by  the  distance  to  which  the  metallic  cylinder  had  to  be  withdrawn  ;  while 
the  strength  of  the  galvanic  current  was  measured  in  milliamperes  by  a  Gaiffe  galva- 
nometer, and  the  strength  of  the  current  was  regulated  by  a  rheostat. 


376 


Hun,  Alcoholic  Paralysis. 


[April 


muscles ;  circumference  of  thigh  three  inches  above  knee-joint  where  the 
thigh  is  smallest  is,  left  13J  inches,  right  13J  inches.  Greatest  circum- 
ference of  calf  of  leg  is  12^-  inches,  and  is  the  same  on  each  side. 

The  cardiac  murmur  has  disappeared.  Slight  murmur  in  carotids  on 
deep  pressure. 

Case  II  A  male,  set.  28,  single;  by  occupation  a  barber;  ex- 
amined Oct.  23d,  1882.  Until  the  past  year  patient  has  always  enjoyed 
good  health,  and  denies  ever  having  had  any  venereal  disease.  He  has  for 
a  long  time  indulged  too  freely  in  alcoholic  drinks,  and  for  six  months 
previous  to  his  present  illness  he  had  been  continuously  under  the  influ- 
ence of  liquor,  although  he  did  not  have  any  attack  of  delirium  tremens. 
As  long  as  a  year  ago  it  was  noticed  that  he  seemed  to  be  lazy,  and  it  is 
only  recently  that  his  family  have  seen  that  his  laziness  is  due  to  weak- 
ness. During  the  past  year  he  has  frequently  said  and  done  very  foolish 
things,  and  during  the  months  of  last  August  and  September  he  stayed 
away  from  his  home  and  could  not  be  induced  to  return  to  it,  because  he 
imagined  that  his  family  were  not  treating  him  as  they  ought. 

During  the  past  six  months  he  has  been  gradually  but  evidently  losing 
strength  in  his  legs,  and  during  the  past  month  or  two  he  has  also  been 
losing  strength  in  his  arms.  His  memory  has  also  failed  greatly,  and  at 
times  he  talks  in  a  foolish  manner.  During  the  past  two  weeks  he  has 
been  confined  to  his  bed  by  weakness,  and  during  the  past  week  he  has 
been  unable  to  sit  up  in  bed  without  assistance.  About  a  week  ago  he 
slipped  off  his  chair  and  was  unconscious  for  a  quarter  of  an  hour,  during 
which  time  he  had  general  convulsive  movements,  but  did  not  bite  his 
tongue. 

Complains  now  of  general  weakness,  of  numbness  of  hands  and  feet, 
and  of  severe  pricking  pain  under  his  nails.  No  other  abnormal  sensa- 
tions in  legs  or  arms.  Says  that  left  arm  and  leg  are  weaker,  more  tender, 
and  more  painful  than  the  right.  Some  time  ago  had  a  slight  pain  in  his 
back,  but  not  lately.  Has  not  had  any  headache,  no  noises  in  ears  or 
head,  but  is  dizzy  at  times.  Insomnia.  No  cough  nor  pain  in  chest. 
Appetite  has  been  good,  but  is  poor  now  ;  digestion  good.  Bowels  slightly 
constipated.  No  delusions,  but  patient  is  very  hopeful,  and  treats  his 
sickness  very  lightly. 

No  facial  nor  ocular  paralysis.  Tongue  protruded  straight.  Pupils 
equal,  and  react  normally.  Speech  is  at  times  normal,  at  other  times 
indistinct  and  explosive.  General  hyperesthesia  of  arms,  legs,  and  body, 
especially  of  abdomen  and  calves  of  legs.  He  shrinks  away  in  a  nervous 
manner  from  the  slightest  touch  on  the  abdomen.  With  the  exception 
of  the  hyperesthesia  the  conduction  of  tactile,  painful,  and  thermic  im- 
pressions is  normal.  No  retardation  of  the  conduction  of  pain.  No 
absolute  paralysis  of  any  muscle,  but  a  very  extreme  degree  of  paresis  of 
all  muscles.  Can  scarcely  walk  when  supported  on  both  sides.  Grasp 
of  hand  weak.  All  movements  are  painful — legs  greatly  emaciated. 
Arms  scarcely  at  all  so.  Very  slight  ataxia  of  legs.  Movements  of 
fingers  awkward.  Patellar  reflex  absent.  Cutaneous  reflexes  well  marked. 
Neither  tenderness  nor  rigidity  nor  deformity  of  head  or  spinal  column.  > 
Left  arm  and  leg  seem  weaker  than  the  right. 

At  this  time  the  patient  was  taking  several  grains  of  opium  daily  to 
procure  sleep.  This  was  ordered  to  be  gradually  diminished.  He  was 
also  chewing  tobacco  freely,  and  this  he  would  not  entirely  stop,  but  con- 
sented to  reduce  the  quantity. 


1885.] 


Hun,  Alcoholic  Paralysis. 


377 


The  galvanic  current  was  applied  daily  for  ten  minutes,  the  positive 
pole  on  the  nape  of  the  neck,  and  the  negative  pole  rubbed  over  the  arms 
and  legs,  and  liq.  potass,  arsenitis  Ti^iij  was  given  three  times  a  day,  and 
a  laxative  pill  at  night. 

November  25.  Has  steadily  lost  strength.  Can  move  his  left  leg  but 
little,  and  cannot  raise  the  right  foot  from  the  bed.  Cannot  raise  himself 
up  in  bed.  Movements  of  the  arms  are  also  weaker,  and  he  cannot  exe- 
cute any  delicate  movements.  All  the  muscles  of  the  body  have  rapidly 
atrophied,  so  that  the  patient  is  much  emaciated. 

Complains  greatly  of  neuralgic  pains  and  of  cramps  in  his  legs,  and 
he  always  feels  cold.  General  hyperesthesia  of  the  skin,  and  pain  on 
compressing  the  muscles  still  continues.  Bladder  and  rectum  act  normally 
but  sluggishly.  Eats  very  little,  and  does  not  sleep  well,  although  he 
takes  a  couple  of  grains  of  opium  at  bedtime.  Mental  condition  is  very 
variable  ;  at  one  minute  he  talks  sensibly  and  the  next  minute  is  very 
delirious.  The  application  of  the  electricity  causes  him  much  pain.  The 
liq.  potass,  arsenitis  was  omitted,  and  in  its  place  a  pill  composed  of  ferri 
redacti  grs.  ij,  and  strychnie  sulph.  gr.  3L  was  given  t.  i.  d. 

December  10.  The  general  muscular  atrophy  continues  to  increase. 
There  is  no  fibrillar  contraction  of  the  muscles  even  when  they  are 
mechanically  irritated,  except  in  the  case  of  the  right  gastrocnemius  after 
the  application  of  electricity ;  this  muscle  manifesting  fibrillar  contrac- 
tion for  an  hour  or  more  after  the  application  of  electricity.  In  all  other 
respects,  except  the  muscular  atrophy,  he  has  improved.  He  cannot  stand, 
but  he  can  raise  himself  up  and  sit  on  the  edge  of  the  bed  and  get  into  bed 
again  without  assistance.  He  can  raise  his  right  foot  easily  from  the  bed. 
The  patellar  refiex  is  still  absent.  His  movements  are  slow,  stiff,  awkward, 
and  painful.  The  hyperesthesia  of  skin  and  muscles  is  much  less  marked, 
and  he  complains  less  of  pain  and  cramps  in  legs  and  numbness  of  hands. 
Is  less  sensitive  to  the  electricity.  His  appetite  is  better,  and  he  sleeps 
better,  although  he  takes  only  -J  gr.  of  opium  at  bedtime,  now. 

All  the  muscles  of  the  arms  and  legs  respond  readily  to  the  faradic 
current  when  a  strong  current  is  employed.  (The  instrument  made  by 
the  Galvano-Faradic  Manufacturing  Co.,  New  York,  two  cells  being  in 
operation,  and  the  metallic  cylinder  withdrawn  4  inches.)  The  extensor 
longus  digitorum  of  left  leg,  however,  will  not  respond  to  any  force  of  the 
current ;  and  in  general  the  muscles  of  the  left  leg  respond  less  readily 
than  those  of  the  right  leg. 

The  electro-motor  excitability,  as  shown  by  the  galvanic  current,  was 
measured  in  milliamperes  by  a  Gaiffe  galvanometer. 

-r>  ,    .        (right,  6  milliamperes. 

Jreroneus  nerve,  negative  closing,  |je°t     g  tt 

Tibialis  anticus  muscle, 

Ulnaris  nerve  at  elbow, 

Median  nerve  at  elbow, 

Flexor  sublimis  digitorum,  2d  &  3d  fingers,  (right,  3 

negative  closing,  (left,-  4 

Flexor  sublimis  digitorum,  1st  &  4th  fingers,  ( right,  3  J 

negative  closing,  (left,  3| 


right,  5 
left,  5 
(right,  2| 
(left,  2| 
(right,  2-| 
lleft,  2f 


378 


Hun,  Alcoholic  Paralysii 


[April 


January  5,  1883.  Great  and  general  diminution  of  the  excitability  of 
the  muscles  to  the  faradic  current.  The  flexors  of  the  index  fingers  con- 
tract but  very  slightly  to  the  strongest  faradic  current.  The  extensor 
longus  digitorum  of  left  leg  does  not  respond  at  all  to  the  faradic  current, 
and  the  corresponding  muscle  of  the  right  leg  responds  but  very  slightly. 
After  this  date  there  was  no  examination  of  the  muscles  made  with  the 
faradic  current. 

24th.  Excitability  of  the  muscles  to  the  galvanic  current  expressed  in 
milliamperes  is  as  follows  : — 

(right,  negative  closing,  lijr;  positive  closing,  Sj 
(left,         "  "      2f;       "         "  6^ 


Tibialis  anticus  muscle, 


(right,       "  "3;         "         "  6 

"[left,  "  "3;  "8 


Extensor  longus  digito-  j  right,       "  "      5;         "  "7 

rum,  (left,    no  reaction  could  be  obtained. 

Median  nerve  at  elbow,  jg1'  ^gative  closing,  2;  positive  closing,  6 

tti  ,   iu  ^ight,       "  "      3|;        "         "  3 

Ulnar  nerve  at  elbow,     jle°t>  '       «  «      g %  .       «         «  g 

Flexor  sublimis  digito-    (right,  "  "4;  "  "  7 

rum,  2d  &  3d  fingers,    (left,  "  "      4 ;  "  "  7 

Flexor  sublimis  digito-    (right,  "  "      3 ;  "  "  5 

rum,  1st  &  4th  fingers,  {left,  "  "      3;  "  "  5 

On  the  right  side  the  index  finger  moves  more  than  the  little  finger, 
while  on  the  left  side  the  little  finger  moves  more  than  the  index  finger. 
All  the  muscles  respond  even  to  a  very  strong  galvanic  current  only  by 
very  slight  contraction.  The  electrical  examination  is  rendered  very 
difficult  by  the  great  irritability  of  the  patient. 

The  general  atrophy  of  the  muscles  of  the  arms,  legs,  face,  and  body 
has  steadily  increased,  and  he  is  approaching  the  condition  of  a  living 
skeleton.  There  is  no  fibrillar  contraction  of  the  rapidly  atrophying 
muscles.  He  can  move  himself  about  in  bed  much  better  than  when  I 
first  saw  him,  but  not  so  well  as  he  could  a  month  ago. 

He  is  very  averse  to  getting  out  of  bed.  Grasp  of  hands  is  weak.  His 
feet  are  drawn  down  and  held  rigidly  in  a  condition  of  plantar  flexion. 
Toes  also  held  in  position  of  plantar  flexion.  Sensibility  to  tactile,  pain- 
ful, and  thermic  impressions  intact.  The  hyperesthesia  of  skin  and 
muscles  has  almost  entirely  disappeared ;  and  the  hyperesthesia  of  the 
abdomen  is  very  slight.  He  is  still  a  little  nervous  about  having  his 
abdomen  touched,  although  he  himself  can  make  firm  pressure  upon  it. 
His  appetite  is  rather  better.  For  a  long  time  his  mind  was  quite  clear, 
but  for  the  last  day  or  two  he  has  again  been  a  little  delirious. 

All  medicine  was  omitted  except  a  laxative  and  a  hypnotic  pill  at  night. 

R.  Iodide  of  potassium,  grs.  vi,  was  given  t.  i.  d. 

February  5.  No  decided  change,  except  that  he  is  eating  better,  and 
requires  no  hypnotic.  Indeed,  he  sleeps  the  greater  part  of  the  day  and 
night.    Iodide  of  potassium  was  increased  to  grs.  x,  t.  i.  d. 

Circumference  of  knee-joint,  12  inches. 

Circumference  a  little  below  knee,  1\  (i 

Greatest  circumference  of  calf  of  leg,  7  " 

Greatest  circumference  of  thigh,  7  J  " 


1885.] 


Hun,  Alcoholic  Paralysis. 


379 


Measurements  are  the  same  on  both  legs. 

Patient  refuses  any  further  application  of  electricity  on  account  of  the 
pain  it  causes. 

March  5.  Has  eaten  almost  nothing  lately.  Will  not  even  take  milk. 
Is  very  weak.  Has  emaciated  so  much  that  he  is  almost  nothing  but 
skin  and  bone.  Muscles  of  face  partake  in  the  general  atrophy.  Can 
move  his  hands  and  arms  pretty  well.  Grasp  of  hand  as  measured  by 
Mathieu's  dynamometer  shows  left  25,  right  38.  Slight  voluntary  motion 
of  muscles  of  thigh  is  still  retained.  Complete  paralysis  of  muscles 
below  the  knee.  Slight  dulling  of  sensibility  of  skin  of  feet  and  lower 
leg  to  tactile,  but  not  to  painful  impressions.  Well-marked  retardation 
(about  two  seconds)  of  conduction  of  painful  impressions  from  feet.  Skin 
of  legs  is  still  somewhat  hypersesthetic,  and  passive  motion  of  leg  causes 
much  pain.  No  tendon  reflexes.  Cutaneous  reflexes  well  marked. 
Patient  will  not  permit  an  electrical  examination  to  be  made.  Bowels 
regular.    Pulse  rapid,  weak,  dichrotic. 

loth.  Yesterday  a  decided  change  appeared  in  patient.  Lies  in  a 
semi-comatose  condition,  from  which  he  is  easily  aroused  to  answer  ques- 
tions. Answers  are  rational.  Bowels  are  regular.  Urine  free,  and  he 
asks  for  bed-pan  and  urinal  when  he  needs  them.  During  the  past  three 
days  the  left  arm  has  become  paralyzed.  The  paralysis  appeared  first  in 
the  deltoid,  then  extended  to  biceps  and  triceps,  and  then  to  muscles  of 
forearm,  very  slight  motion  of  fingers  and  hand  alone  remaining.  Motion 
of  right  arm  is  almost  as  good  as  it  was  a  week  ago.  The  muscles  of  the 
legs  are  completely  paralyzed.  Cannot  raise  his  voice  above  a  whisper. 
Will  drink  only  a  little  wine. 

loth.  Consciousness  clear.  Voice  growing  gradually  weaker.  Has  an 
occasional  dejection  in  bed. 

l§th.  Died  quietly  last  night. 

11th.  Autopsy  thirty-six  hours  after  death. — Extreme  emaciation  of 
whole  body.  Several  spots  of  purpura  hemorrhagica  over  anterior  aspect 
of  left  upper  arm.  No  hypostasis.  Post-mortem  rigidity  not  present. 
Muscular  tissue  very  slight  in  amount.  No  decided  replacing  of  muscular 
fibres  by  connective  tissue  could  be  seen  by  the  naked  eye. 

No  decided  abnormality  about  thoracic  or  abdominal  organs  except 
general  atrophy  and  dryness. 

Brain — Veins  of  pia  mater  full  of  blood.  Unusually  large  quantity 
of  sub-arachnoid  fluid  over  the  surface  of  the  hemispheres.  No  enlarge- 
ment of  the  ventricles,  and  very  slight  atrophy  of  the  cerebral  convolu- 
tions. Sections  through  the  hemispheres,  the  ganglia  at  the  base,  and  the 
cerebellum,  appear  normal  to  the  naked  eye. 

Spinal  Cord — Slight  adherence  of  the  dura  and  the  pia  mater  in  the 
cervical  region  of  the  cord,  but  no  marked  congestion  of  the  membranes 
nor  other  sign  of  meningitis.  On  section,  the  spinal  cord  appears  normal 
to  the  naked  eye. 

Microscopic  Examination  A  number  of  sections  of  several  parts  of 

the  cortex,  especially  of  the  central  convolutions,  show  a  decided  degen- 
eration of  the  nerve-cells  in  the  cortex.  Although  the  brain  is  well 
hardened  the  nerve-cells  are  so  granular  that  their  nucleus  can  scarcely 
be  made  out,  and  the  cells  themselves  are  rounded  and  contracted  so  that, 
instead  of  being  surrounded  by  a  small  lymph  space,  they  seem  to  be 
lying  in  large  cavities.  There  is  also  a  slight  increase  in  the  number  of 
small  round  cells  in  the  cortex  and  in  the  adjoining  parts  of  the  white 


380 


Hun j  Alcoholic  Paralysis. 


[April 


matter.  A  large  number  of  sections  of  the  medulla  oblongata  and  spinal 
cord,  especially  of  the  cervical  and  lumbar  enlargements,  show  these 
organs  to  be  entirely  normal,  and  in  particular  the  nerve-cells  in  the 
anterior  horns  are  unusually  well  stained  and  sharply  defined. 

Unfortunately,  pieces  of  the  peripheral  nerves  and  muscles  were  not 
preserved. 

If  we  review  in  a  general  way  the  symptoms  of  these  two  cases,  we 
find :  First.  Sensory  disturbances  in  the  form  of  neuralgic  pains  and 
paresthesias,  pain  on  pressure  over  the  muscles  and  on  passive  motions, 
a  mixture  of  cutaneous  hyperesthesia  and  anaesthesia,  and  retardation  of 
the  conduction  of  pain.  Second.  Motor  disturbances  in  the  form  of  mus- 
cular weakness,  which  rapidly  increases  in  intensity  and  is  accompanied 
by  muscular  atrophy  without  fibrillar  contraction  and  by  the  electrical 
reaction  of  degeneration,  or  at  least  an  approach  to  this  reaction.  And, 
third.  Ataxic  disturbances  which  are  associated  with  a  loss  of  the  tendon 
reflexes,  while  the  cutaneous  reflexes,  especially  the  plantar  reflex,  are 
increased.  All  these  disturbances  are  symmetrically  distributed.  They 
appear  first  and  most  decidedly  in  the  legs  and  then  extend  to  the  arms, 
where  they  are  less  severe.  Associated  with  these  symptoms  is  a  greater 
or  less  degree  of  mental  weakness  and  derangement. 

Such  a  combination  of  sensory  disturbances,  absence  of  patellar  reflex, 
ataxia,  muscular  paralysis  and  muscular  atrophy,  is  very  uncommon,  and 
there  can  be  but  little  doubt  that  these  two  cases  which  possess  these  and 
other  characters  in  common  are  due  to  the  same  lesion.  There  is,  however, 
a  great  difference  in  the  severity  of  the  symptoms  in  the  two  cases.  In  the 
first  case  the  initial  sensory  disturbances  and  the  cutaneous  and  muscular 
hyperaesthesia  were  only  slightly  marked,  the  pain  on  passive  motion  was 
entirely  absent,  and  there  was  only  a  slight  degree  of  muscular  atrophy. 
In  the  second  case,  not  only  were  all  these  symptoms  extremely  well 
marked,  but  in  addition  there  was  retardation  of  the  conduction  of  pain, 
and  the  disease  terminated  fatally  after  the  muscular  atrophy  had  become 
so  extreme  that  the  patient  was  reduced  to  the  condition  of  the  so-called 
"  living  skeletons." 

In  regard  to  the  anatomical  lesion  associated  with  these  symptoms,  it  is 
evident  that  it  must  be  situated  somewhere  in  the  cerebro-spinal  nervous 
system  ;  that  is,  either  in  the  brain,  or  spinal  cord,  or  in  the  peripheral 
nerves,  or  simultaneously  in  one  or  more  of  these  divisions.  The  lesion 
cannot  be  in  the  brain  alone,  for  no  lesion  of  the  brain  can  cause  absence 
of  tendon  reflex,  rapid  muscular  atrophy,  reaction  of  degeneration,  etc. 
All  the  symptoms  in  the  case,  except  the  mental  disturbance,  might  be 
explained  by  a  lesion  of  the  spinal  cord,  provided  that  the  lesion  was 
situated  in  the  anterior  horns  of  gray  matter  and  in  the  posterior  columns 
of  white  matter;  so  that  a  combination  of  the  symptoms  of  poliomyelitis 
anterior  and  of  locomotor  ataxia  would  result,  although  in  these  cases 


1885.] 


Hun,  Alcoholic  Paralysis. 


381 


several  symptoms  of  locomotor 'ataxia  are  absent.  Not  only  is  it  very 
improbable  that  two  portions  of  the  spinal  cord  so  widely  separated  from 
each  other,  both  by  space  and  by  function,  as  the  posterior  columns  and 
the  anterior  horns,  should  be  simultaneously  attacked  by  disease,  while  the 
rest  of  the  spinal  cord  remained  healthy,  but  a  careful  examination  of  the 
spinal  cord  in  the  second  case  revealed  no  trace  of  disease.  By  a  process 
of  elimination  then  it  becomes  altogether  probable  that  the  lesion  is 
situated  in  the  peripheral  nerves.  At  first  sight  it  may  seem  improbable 
that  such  a  general,  wide-spread,  primary  inflammation  of  the  peripheral 
nerves  should  occur,  but  it  is  now  well  known  that  many  cases,  formerly 
called  myelitis  of  the  anterior  horns,  are  really  due  to  a  general  neuritis 
of  the  smaller  branches  of  the  peripheral  nerves,  the  larger  trunks 
being  only  slightly  or  not  at  all  affected.  Leyden1  described  the  disease 
very  accurately,  and  gave  it  the  name  of  multiple  neuritis,  and  since  that 
time  it  has  been  called  by  that  name.  The  symptoms  of  multiple  neuritis 
resemble,  in  respect  to  muscular  paralysis  and  atrophy,  very  closely  those 
of  myelitis  of  the  anterior  horns,  but  in  addition  to  these  motor  symp- 
toms there  are  many  symptoms  of  sensory  disturbance,  viz.,  neuralgic 
pains,  paramnesias,  hyperesthesias,  muscular  tenderness,  anesthesia, 
retardation  of  the  conduction  of  pain,  absence  of  tendon  reflexes,  etc. ; 
these  sensory  symptoms  being  absent  in  myelitis  of  anterior  horns  ;  and 
the  prominence  of  these  sensory  disturbances  often  enables  us  to  decide 
whether  a  case  is  one  of  multiple  neuritis  or  of  myelitis  of  the  anterior 
horns.  The  symptoms,  therefore,  of  multiple  neuritis  are  very  similar  to 
those  of  the  two  cases  above  reported,  and  in  the  absence  of  any  change 
in  the  spinal  cord  of  our  second  case,  it  is  very  probable  that  the  lesion 
was  in  the  peripheral  nerves,  and  especially  so  since,  in  some  cases  of 
alcoholic  paralysis  reported  by  Lancereaux,2  Dejerine,3  and  others,  degen- 
erative processes  were  found  in  the  peripheral  nerves,  while  the  spinal 
cord  was  healthy. 

The  supposition  of  a  general  neuritis  would  explain  the  symptoms  of 
these  cases  very  well.  The  inflammation  of  the  nerves  would  account  for 
the  neuralgic  pains  and  the  paresthesia  which  are  met  with  in  the  com- 
mencement of  the  disease.  Along  the  inflamed  nerves  the  conduction  of 
nervous  impulses  would  be  both  difficult  and  painful,  and  would  thus  give 
rise  to  muscular  weakness  and  hyperesthesia,  and  perhaps,  also,  to  the 
retardation  of  the  conduction  of  pain.  The  inflamed  and  degenerated 
nerves  would  naturally  give  rise  to  the  reaction  of  degeneration,  and 
would  cause,  also,  the  rapid  muscular  atrophy  ;  and  when  the  nerves 
become  destroyed  by  the  inflammation  muscular  paralysis  and  cutaneous 
and  muscular  anesthesia  would  result.    The  destruction  of  the  nerve- 

1  Zeitschrift  fur  klinische  medicin,  vol.  i.  p.  387. 

2  Gazette  des  HSpitaux,  1883,  No.  40 ;  Gazette  Hebdom.,  1881,  Nos.  45  and  118. 

3  Archiv.  de  Physiol,  norm,  et  pathol.,  1884,  No.  2,  p.  231. 

No.  CLXXVlil  Apkil,  1885.  25 


382 


Hun,  Alcoholic  Paralysis. 


[April 


fibres  of  muscular  sense  would  explain  the  loss  of  the  tendon  reflex,  the 
ignorance  of  the  patient  as  to  what  position  his  legs  were  in,  and  the 
ataxia  in  part  at  least.  Of  course  the  mental  symptoms  could  not  be  due 
to  any  disease  of  the  peripheral  nerves,  but  must  be  due  to  a  change  in 
the  cerebral  cortex,  and  this  change  in  the  second  case  was  found  to  be  a 
degeneration  and  shrinking  up  of  the  nerve-cells  in  the  cortex,  and  a 
congestion  of  the  pia  mater  and  effusion  of  serum  in  the  subarachnoid 
space.  The  ataxia  might  also  be  due,  in  part  at  least,  to  cerebral  distur- 
bance, for  it  was  associated  with  tremor,  and  in  its  appearance  resembled 
the  uncertain  movements  made  by  a  drunken  man,  which  form  of  inco- 
ordination is  probably  of  cerebral  origin.  It  seems  probable,  then,  that 
the  lesion  of  the  nervous  tissue  occurring  in  alcoholic  paralysis  is  a  degene- 
ration of  the  nerve-cells  in  the  cerebral  cortex,  and  of  the  nerve-fibres  in  the 
smaller  peripheral  nerves,  while  the  spinal  cord  is  normal,  and  the  nerve- 
cells  lying  in  the  anterior  horns  exhibit  not  the  slightest  degeneration  nor 
change. 

That  the  disease  attacks  especially  the  small  nerve  branches  and  not 
the  nerve  trunks,  is  indicated  in  the  first  case  by  the  action  of  the  right 
tibialis  anticus  muscle  to  electricity.  The  muscular  fibres  respond 
readily  to  the  galvanic  current  with  a  reversal  of  the  formula,  that  is,  the 
positive  pole  becomes  the  most  active,  but  the  nerve  filaments  are  so 
degenerated  that  they  cannot  be  directly  excited  by  the  faradic  current, 
although  they  will  still  transmit  strong  impulses  from  the  nerve  trunk  which 
remains  excitable  to  the  faradic  and  galvanic  current.  The  left  tibialis 
anticus  muscle  shows  the  same  thing,  but  less  decidedly.  Indications  of 
the  same  thing  are  furnished,  though  less  clearly,  by  the  electrical  exami- 
nation of  the  second  case.  The  electrical  examination  of  the  second  case 
was,  however,  much  less  satisfactory,  and  is  less  reliable  than  that  of  the 
first  case,  partly  because  of  the  want  of  a  suitable  place  and  of  proper 
appliances  for  the  testing,  and  chiefly  because  of  the  great  irritability  of 
the  patient. 

In  regard  to  the  treatment  of  these  cases  :  iodide  of  potassium  was  in  the 
beginning  given  freely  to  the  first  case.  Under  this  treatment  there  was 
only  very  slight  improvement,  and  this-  might  well  be  due  to  the  con- 
tinued rest  in  bed.  Later  strychnia  was  substituted  for  the  iodide  of 
potassium,  and  the  faradic  current  was  daily  applied  to  the  arms  and  legs, 
and  under  this  treatment  the  improvement  was  very  rapid.  The  patient's 
back  was  cauterized  once  or  twice  without  any  apparent  result.  In  the 
second  case  the  galvanic  current  was  employed  on  the  arms  and  legs,  and 
iron  and  strychnia  wrere  given  externally.  For  a  short  time  after  he  com- 
menced taking  the  strychnia  the  patient  improved  decidedly,  but  he  soon 
fell  back  again  and  ultimately  died. 

In  regard  to  the  cause  of  the  disease,  there  is  in  each  case  a  history  of 
excessive  drinking.    In  the  first  case,  when  the  patient  entered  the 


1885.] 


Hun,  Alcoholic  Paralysis. 


383 


hospital  he  had  every  appearance  of  chronic  alcoholism,  general  tremor, 
confusion  of  mind  and  speech,  irritable  stomach,  and  very  well-marked 
acne  rosacea  ;  and  he  did  not  hesitate  to  confess  that  he  had  for  many 
years  drunk  a  very  excessive  quantity  of  whiskey,  etc.  In  the  second  case 
the  family  of  the  patient  gave  an  account  of  very  excessive  drinking. 
The  fact  that  many  other  cases  closely  resembling  these  two,  and  all 
following  excessive  use  of  alcohol,  have  been  reported,  confirms  the  view 
that  we  have  to  do  with  cases  of  disease  which  are  due  to  the  action  on 
the  nervous  system  of  the  long-continued  abuse  of  alcohol. 

The  whole  subject  of  alcoholic  paralysis  is  of  comparatively  recent 
date,  and  it  is  yet  an  open  question  whether  or  not  it  should  be  regarded 
as  a  special  form  of  disease.  A  brief  statement,  therefore,  of  the  cases  of 
this  disease  which  have  been  hitherto  reported  may  lead  to  a  better 
understanding  of  the  subject. 

In  his  great  work  on  chronic  alcoholism,  published  in  1852,  Magnus 
Huss  divides  the  nervous  symptoms  occurring  in  chronic  alcoholism  into 
a  paralytic,  an  anaesthetic,  a  convulsive,  an  epileptic,  and  a  hyperaesthetic 
form  according  to  the  symptom  which  is  most  prominent,  for  in  any  one 
case  a  number  of  the  above  symptoms  may  occur  in  a  greater  or  less 
degree,  and  the  different  forms  cannot  always  be  sharply  separated  from 
each  other.  He  attributes  these  symptoms  to  a  disease  of  the  spinal  cord 
and  medulla  oblongata,  although  he  was  unable  actually  to  demonstrate 
this. 

The  prognosis  is  rather  favorable  when  the  alcohol  can  be  stopped.  In 
1864  Lancereaux  described  the  forms  of  paralysis  due  to  alcohol  more 
systematically  in  the  Dictionnaire  Encyclo'pedique  des  Sciences  medi- 
cates, and  Leudet  added  a  note  to  the  effect  that  these  were  cases  of 
painful  paralysis.  In  1867,  Leudet  published  some  cases  of  the  hyper- 
aesthetic form  of  chronic  alcoholism,  and  considered  that  it  was  of  more 
frequent  occurrence  than  Magnus  Huss  supposed.  In  these  cases  there 
was  not  only  great  hyperaesthesia  of  the  skin,  muscles,  and  bones,  but  also 
neuralgic  pains,  muscular  weakness,  ataxia,  anaesthesia,  increase  of  cuta- 
neous reflexes,  and  in  one  case  retardation  of  the  conduction  of  pain. 
Cerebral  symptoms  were  present  in  some  cases  and  absent  in  others. 
Leudet,  like  Huss,  considers  these  symptoms  as  of  spinal  origin.  In  1868, 
Dr.  Reginald  Thompson  read  before  the  Royal  Medical  and  Chirurgical 
Society  of  England  the  report  of  a  case  of  paralysis  of  the  extensors  due, 
in  part  at  least,  to  alcoholic  excesses. 

In  the  Lancet,  of  1872,  Dr.  S.  Wilks  quotes  from  a  lecture  which  he 
delivered  in  October,  1867,  to  the  effect  that  he  has  seen  many  cases  of 
paraplegia  in  ladies  who  were  addicted  to  alcoholic  excesses,  and  says 
that  since  1867  he  has  seen  a  number  of  similar  cases.  The  symptoms  of 
the  disease,  according  to  Wilks,  are  severe  pains  in  all  the  limbs,  especi- 


384 


Hun,  Alcoholic  Paralysis. 


[April 


ally  the  lower  ones  which  are  much  wasted,  together  with  numbness  and 
considerable  anaesthesia,  and  at  the  same  time  only  slight  power  of  move- 
ment or  total  inability  to  stand.  With  the  addition  of  the  akinesia,  the 
symptoms  are  not  unlike  those  of  ataxia.  'In  one  case  there  was  hyper- 
esthesia. Wilks  considers  the  disease  to  be  due  to  a  change  in  the  struc- 
ture of  the  spinal  cord,  similar  to  that  which  takes  place  in  the  brain  in 
chronic  alcoholism  (viz.,  degeneration  of  the  nervous  tissue  and  thickening 
of  the  membranes),  but  he  offers  no  proof  of  any  such  change.  In  such 
cases  the  prognosis  is  hopeful,  and  the  most  important  thing  in  the  treat- 
ment is  the  immediate  and  complete  stopping  of  all  alcoholic  drinks. 
In  the  same  year  and  journal  (Lancet,  1872),  J.  Lockhart  Clarke 
published  some  cases  similar  to  those  of  Dr.  Wilks,  and  endorsed  Dr. 
Wilks's  views  as  to  the  cause  and  nature  of  the  disease. 

In  1879,  Westphal1  described  a  peculiar  form  of  walking  in  cases  of 
chronic  alcoholism  which  presented  a  certain  resemblance  to  locomotor 
ataxia.  The  peculiarity  of  this  kind  of  walking  consists  in  lifting  the  leg 
very  high  so  that  the  thigh  is  flexed  strongly  on  the  body,  and  then 
bringing  the  leg  strongly  down  to  the  ground  with  a  stamp.  . 

In  1881,  Lancereaux2  published  a  number  of  cases  of  alcoholic  paralysis 
in  which  the  disease  commenced  with  sharp  pains  in  the  legs,  followed  by 
a  combination  of  anaesthesia  and  hyperesthesia,  and  a  motor  paresis. 
The  symptoms  are  frequently  confined  to  the  legs,  and  when  the  arms  are 
involved,  the  symptoms  occur  especially  in  the  distribution  of  the  radial 
nerves.  The  disease  is  more  common  in  women  than  in  men  (12  women 
out  of  15  cases),  and  the  patients  are  affected  by  other  symptoms  of 
alcoholism.  There  are  no  contractures.  The  faradic  electro-motor  excita- 
bility is  diminished  or  abolished.  On  careful  microscopic  examination  of 
several  cases,  no  change  was  found  in  any  part  of  the  nervous  system 
except  that  the  nerves  of  the  affected  extremities  showed  evident  changes. 
The  myelin  was  segmented  and  run  into  drops,  and  some  sheaths  were 
empty  and  collapsed,  and  the  nuclei  of  Schwann  were  somewhat  nearer 
together  than  normal.  These  changes  did  not  however  affect  the  whole  of 
the  nerve.  In  1883,  Lancereaux3  describes  alcoholic  paralysis  as  being- 
symmetrical,  attacking  either  the  upper  or  lower  extremities,  and  gradu- 
ally extending  towards  the  body.  The  lower  extremities  are  always  more 
affected  than  the  upper,  and  the  extensor  than  the  flexor  muscles.  The 
electrical  excitability  is  greatly  diminished,  and  extensive  anaesthesia  is 
often  present.  In  such  cases  the  brain  and  spinal  cord  were  found  to  be 
normal,  while  the  muscles  and  the  peripheral  nerves  showed  extensive 
degenerative  changes. 

1  Charite  Annalen,  iv.  Jarhgang,  1879,  p.  395. 

2  Gazette  Hebdom.,  Nos.  45  and  188. 

3  Gazette  des  Hopitaux,  No.  16,  1883. 


1885.] 


Hun,  Alcoholic  Paralysis. 


385 


In  August,  1882,  Dr.  Myrtle  published  in  the  British  Medical  Journal 
a  rather  imperfectly  observed  case  of  alcoholic  paralysis,  and  in  the  same 
year  Dr.  G.  Fisher1  reported  two  cases  of  alcoholic  paralysis,  which  were 
very  accurately  examined  and  described,  and  of  which  he  gives  the  follow- 
ing summary :  — 

"  Two  men  of  a  very  low  order  of  intelligence,  almost  imbeciles,  who  had  no 
hereditary  nor  syphilitic  taint,  in  consequence  probably  of  the  habitual  abuse 
of  alcohol,  of  excessive  smoking,  and  of  an  indolent  life,  presented  a  complex  of 
very  severe  disturbances  of  innervation,  together  with  decided  symptoms  of  mental 
derangement.  The  symptoms  were  paresis  of  all  the  muscles  connected  with  the 
spinal  cord,  muscular  atrophy  with  diminution  of  absence  of  the  electric  excita- 
bility, a  remarkable  hardness  and  remarkable  sensitiveness  on  pressure  of  the 
paretic  muscles,  loss  of  mechanical  excitability  and  of  the  patellar  reflex,  evident 
ataxia,  slight  initial  paresthesias,  dulling  of  tactile  sensibility,  retardation  of  the 
conduction  of  pain,  peculiar,  but  sharply  defined  abnormalities  of  the  perception 
of  pain.  Remarks  double  perception,  retardation  of  the  cutaneous  reflexes.  In 
addition  to  the  above  symptoms  there  were  slight  febrile  and  gastric  disturbances, 
rapid  pulse,  and  signs  of  diminished  heart  force.  No  strong  subjective  symptoms 
in  the  domain  of  sensibility;  no  lancinating  pains;  no  girdle  sensation,  neither 
rigidity  nor  pain,  nor  sensitiveness  of  spinal  column.  The  vegetative  functions 
and  sphincters  intact.  The  functions  of  the  cranial  nerves  normal,  except  for 
slight  abnormality  of  the  pupil,  probably  due  to  other  causes.  In  the  first  case 
recovery,  in  the  second  decided  and  permanent  improvement." 

From  a  consideration  of  the  symptoms  in  these  cases  Fischer  concludes 
that  the  lesion  is  a  subacute  inflammation  of  the  gray  matter,  the  pos- 
terior columns,  and  the  inner  portion  of  the  lateral  columns  of  the  spinal 
cord,  and  admits  the  possibility  also  of  a  lesion  of  the  peripheral  nerves. 

In  July,  1883,  Dr.  R.  Glynn  reported  several  cases  of  alcoholic  para- 
plegia in  the  Liverpool  Medico-Chirurgical  Journal. 

At  a  meeting  of  the  Royal  Medical  and  Chirurgical  Society,  held  on 
February  12,  1884,  Dr.  Broadbent  reported  a  case  of  alcoholic  paralysis 
in  which  the  paralysis  came  on  insidiously,  and  attacked  especially  the 
extensors ;  the  patellar  reflex  was  absent,  and  there  was  no  disturbance  of 
the  sphincters  nor  of  sensation.  No  pain,  but  there  was  hyperesthesia. 
The  hands  and  feet  were  pale,  puffy,  and  purplish.  (This  condition  of 
cedema  was  noticed  in  a  number  of  cases  which  had  been  previously  re- 
ported.) The  case  of  Dr.  Broadbent  quickly  terminated  fatally,  and  a 
careful  microscopic  examination  revealed  nothing  abnormal.  In  the  dis- 
cussion following  this  case,  Dr.  Wilks  reiterated  his  views  as  to  this  dis- 
ease which  he  had  published  in  the  Lancet  twelve  years  before.  He  was 
constantly  meeting  with  such  cases,  which  recovered  when  the  alcohol  was 
withdrawn.  Alcohol,  in  his  opinion,  acted  on  the  whole  cerebro-spinal 
system,  though  the  spinal  cord  might  be  more  affected  in  many  cases.  No 
change  had  hitherto  been  found  in  the  true  neural  substance  of  the  brain 
or  cord,  though  these  organs  might  be  wasted  and  their  meninges  thick- 
ened. 

1  Archiv.  fiir  Psychiatrie  und  Nervenkrankheiten,  vol.  xiii.  p.  1. 


386 


Hun,  Alcoholic  Paralysis. 


[April 


Dr.  Buzzard  spoke  of  a  number  of  cases  which  he  had  seen,  and  called 
attention  to  the  lancinating  pains  and  the  muscular  atrophy  which  were 
often  present.  He  said  that  in  alcoholic  paraplegia  there  was  a  diminu- 
tion or  loss  of  response  to  the  faradic  current,  with  exaggerated  response 
to  the  galvanic  current.  These  facts  showed  the  disease  to  be  of  spinal 
order.  In  alluding  to  the  fact  that  Lancereaux  had  found  degenerative 
processes  in  the  peripheral  nerves,  Dr.  Buzzard  stated  that,  in  1880, 
Mr.  de  Watteville  had  suggested  that  a  dynamic  change  in  the  cells  of  the 
anterior  horns  of  a  temporary  character  might  be  sufficient  to  cause  de- 
generative changes  in  the  peripheral  parts  of  the  nerve-fibres. 

In  the  summer  of  1884,  Dr.  Lbwenfeld1  reported  two  cases,  the  first  of 
which  was  due  to  alcoholic  excesses  and  was  almost  identical  with  the 
cases  reported  by  Fischer  mentioned  above.  The  second  case  was  not  due 
to  alcoholic  excess,  and  differed  in  many  respects  from  the  first  case,  although 
it  presented  a  combination  of  weakness,  ataxia,  and  disturbances  of  sensa- 
tion. From  a  consideration  of  his  cases  Dr.  Lbwenfeld  regarded  the 
lesion  as  being  situated  in  the  spinal  cord.  In  an  appendix  to  his  article, 
however,  written  after  he  had  read  Dejerine's  article,  he  is  led  to  consider 
that  the  symptoms  in  his  first  case  depended  on  a  disease  of  the  peripheral 
nerves,  while  he  continued  to  regard  his  second  case  as  due  to  a  disease  of 
the  spinal  cord. 

In  February,  1884,  J.  Dejerine2  published  two  cases  similar  to  the  first 
two  of  Fischer's,  although  there  was  less  muscular  atrophy  and  paralysis, 
and  the  first  one  of  Lbwenfeld's.  Both  cases  terminated  fatally,  and  at 
the  autopsy  a  neuritis  of  the  peripheral  nerve  was  discovered  with  integ- 
rity of  the  nerve-roots,  the  spinal  ganglion,  and  the  spinal  cord.  By 
Dejerine  these  cases  are  considered  as  a  variety  of  locomotor  ataxia. 

In  Sept.  1884,  Dr.  Kriiche3  published  an  article  on  the  pseudo-tabes 
of  drunkards,  and  pointed  out  the  great  similarity  of  this  form  of  disease  to 
locomotor  ataxia.  He  bases  his  remarks  on  seventeen  patients  that  he 
had  had  in  his  asylum,  and  he  points  out  that  in  the  false  locomotor 
ataxia  of  drunkards  there  is  great  hyperesthesia  to  the  electric  brush, 
and  the  girdle  sensation  is  absent.  On  an  ophthalmoscopic  examination 
of  these  cases  he  found  in  three  cases  the  papilla  white  and  in  nine  cases 
a  venous  fulness  of  the  retina.  • 

Indeed  in  1884  the  literature  of  this  disease  is  quite  abundant,  for  in 
addition  to  that  above  given  Drs.  Moeli4  and  Dreschfield5  have  each 
published  cases  of  alcoholic  paralysis  in  which  degenerative  processes  were 

1  Archiv  f.  Psychiatrie  u.  Nervenkrankheiten,  vol.  xv.  p.  438. 

2  Archiv.  de  Physiologie  norm,  et  pathol.,  No.  2,  1884,  p.  231. 

3  Deutsche  Medizinal  Zeitung,  Sept.  8, 1884. 

4  Charite  Annalen,  1884,  and  Berl.  Klin.  Wochenschrift,  No.  14,  1884. 

5  Brain,  July,  1884. 


1885.] 


Hun,  Alcoholic  Paralysis. 


387 


found  in  the  peripheral  nerves,' and  Charcot1  and  Fere2  have  each  pub- 
lished reviews  of  the  disease;  and  in  the  Lancet  of  August,  1884  (Ameri- 
can reprint),  is  an  editorial  on  alcoholic  paralysis.  Charcot  and  Fere 
state  that  the  muscles  of  the  face  are  never  involved. 

From  the  considerable  number  of  cases  which  have  been  reported  we 
are  justified  in  regarding  alcoholic  paralysis  as  a  special  form  of  disease 
with  the  following  symptoms:  After  a  number  of  cerebral  and  gastric 
disturbances  due  to  the  alcoholic  poisoning  the  symptoms  of  the  disease 
proper  commence  with  neuralgic  pains  and  paresthesias  in  the  legs,  which 
gradually  extend  to  the  upper  extremity,  and  which  are  accompanied  at 
first  by  hyperesthesia,  later  by  anaesthesia,  and  in  severe  cases  by  re- 
tardation of  the  conduction  of  pain.  Along  with  these  symptoms  appears 
a  muscular  weakness,  which  steadily  increases  to  an  extreme  degree  of 
paralysis,  and  is  accompanied  by  rapid  atrophy  and  by  great  sensitiveness 
of  the  muscles  to  pressure  and  to  passive  motion.  Both  the  sensory  and 
the  motor  disturbances  are  symmetrically  distributed,  and  the  paralysis 
attacks  especially  the  extensor  muscles.  In  addition  to  these  motor  and 
sensory  symptoms  there  is  also  a  decided  degree  of  ataxia.  The  tendon 
reflexes  are  abolished,  and  vaso-motor  symptoms,  such  as  oedema,  conges- 
tion, etc.,  are  usually  present.  Symptoms  of  mental  disturbance  are 
always  present  in  the  form  of  loss  of  memory,  and  in  transient  delirium. 

These  symptoms,  with  the  exception  of  the  mental  derangement,  and 
perhaps  the  ataxia  also,  are  very  similar  to  those,  of  multiple  neuritis  not 
dependent  upon  alcoholic  poisoning. 

In  regard  to  the  lesion  associated  with  these  symptoms,  the  spinal  cord 
has  been  found  entirely  normal  in  all  the  cases  in  which  a  post-mortem 
examination  has  been  made.  On  the  other  hand,  during  the  past  four 
years,  degenerative  processes  have  been  found  in  the  peripheral  nerves  in 
a  number  of  cases  of  alcoholic  paralysis.  Lancereaux  has  reported  three 
cases  in  which  such  changes  were  found,  Dejerine  and  Moeli  have  each 
reported  two  such  cases,  and  Dreschfeld  one ;  eight  cases  in  all. 

It  therefore  seems  altogether  probable  that  drunkards  are  especially  sub- 
ject to  multiple  neuritis,  and  that  alcoholic  paralysis  is  simply  multiple 
neuritis  complicated  by  other  symptoms  of  alcoholic  poisoning,  such  as  men- 
tal derangement,  tremor,  and  ataxia.  These  latter  symptoms  seem  to  be 
due  to  changes  in  the  cerebral  cortex,  for  in  the  second  case  reported  in  this 
article  there  was  found  a  degeneration  and  atrophy  of  the  nerve-cells  in 
the  cerebral  cortex,  a  congestion  of  the  pia  mater,  and  an  effusion  of  serum 
in  the  sub-arachnoid  space.  Very  little  attention  appears  to  have  been 
given  to  the  study  of  the  pathological  histology  of  the  cerebral  cortex, 

1  Gazette  des  H6pitaux,  Aug.  28, 1884. 

2  Progrds  Medical,  June  14,  1884. 


388 


Fry,  Intestino-vaginal  Fistula. 


[April 


either  in  eases  of  alcoholic  paralysis  or  in  other  forms  of  chronic  alcoholism, 
but  a  degeneration  of  the  nerve-cells  in  the  cerebral  cortex  similar  to  that 
found  in  the  second  case  has  been  described  by  Dr.  Wilks1  as  occurring 
in  cases  of  chronic  alcoholism.  An  effusion  of  serum  in  the  sub-arachnoid 
space,  and  a  chronic  congestion  or  inflammation  of  the  pia  mater  are  very 
commonly  found  in  cases  of  chronic  alcoholism. 

The  lesion,  then,  in  alcoholic  paralysis,  is  in  all  probability  a  degenera- 
tion of  the  peripheral  nerve-fibres  and  of  the  nerve-cells  in  the  cerebral 
cortex,  together  with  a  chronic  congestion  or  inflammation  of  the  pia 
mater.  This  lesion  explains  well  the  symptoms,  although  it  is  certainly 
curious  that  alcohol  should  not  attack  the  spinal  cord,  but  only  the  highest 
and  the  lowest  part  of  the  nervous  system  if  one  may  so  call  the  cortex  of 
the  brain  and  the  terminal  branches  of  the  peripheral  nerves. 


Article  Y. 

Fistulous  Communications  between  the  Intestines  and  the  Female 
Genital  Canal.    By  H.  D.  Fry,  M.D.,  of  Washington.  D.  C. 

Since  the  application  of  plastic  surgery  to  gynaecological  operations  the 
treatment  of  vesico-vaginal  and  recto-vaginal  fistulas  is  as  well  understood 
as  are  the  etiology  and  symptomatology.  The  result,  though,  when  con- 
trasted with  the  old  tedious  plan  of  cauterization,  is  brilliant  no  less  to  the 
operator  than  to  the  unfortunate  woman  whose  life  is  rendered  miserable 
by  such  conditions. 

The  object  of  this  communication,  however,  is  to  direct  attention  to  less 
frequent  forms  of  fistulas  that  communicate  with  the  genital  canal,  and  to 
place  on  record  a  case  of  intestino-vaginal  fistula.  These  fistulas  are  of 
infrequent  occurrence,  because,  as  Fetit  has  remarked,  the  conditions  that 
give  rise  to  the  complication  are  rare,  and  because,  I  might  add,  when  met 
with,  they  are  of  such  grave  character  that  death  generally  results  before, 
or  at  any  rate  soon  after,  the  development  of  the  fistula.  The  reports  of 
cases  to  be  found  in  medical  literature  are,  in  consequence  of  this  fatality, 
quite  satisfactory  as  to  cause,  nature  of  the  lesion,  and  parts  involved,  the 
information  being  usually  obtained  by  post-mortem  examination. 

L.  H.  Fetit  has  collected  thirty-eight  cases  and  published  them, 
together  with  a  review  of  the  subject,  in  the  Annates  de  Gynecologie  for 
1883.2  Of  this  number  the  nature  of  the  lesion  was  ascertained  in  all  but 
three.  The  intestines  and  vagina  were  united  by  a  fistulous  tract  twenty- 
three  times,  and  the  intestines  and  uterus  thirteen.    In  one  of  the  uterine 

1  Journal  of  Mental  Sciences,  1864. 

2  I  regret  that  I  have  not  been  able  to  consult  the  original  article. 


1885.] 


Fry,  Intestino-vaginal  Fistula. 


389 


cases  the  intestinal  opening  could  not  be  located,  and  in  two  of  the  intes- 
tino-vaginal fistula?  communications  also  existed  with  the  bladder. 

Among  the  causes  giving  rise  to  these  lesions  may  be  enumerated  can- 
cer, pelvic  cellulitis  and  abscess,  difficult  labor,  and  affections  of  the  intes- 
tinal canal,  as  obstruction,  strangulation,  intussusception,  typhlitis,  and 
perityphlitic  abscess.  Less  often  it  may  result  from  extra-uterine  preg- 
nancy, hyo-  and  pyo-salpinx. 

Cancerous  ulcerations  may  extend  from  the  uterus  or  vagina  directly  to 
the  large  or  small  intestines,  or  more  indirectly  by  invading  intervening 
structures  and  bands  of  adhesive  lymph  produced  by  accompanying  peri- 
tonitis. The  late  Marion  Sims,  with  his  extensive  experience  in  uterine 
diseases,  had  met  with  but  two  cases  of  fistulous  communication  between 
the  fundus  uteri  and  rectum  resulting  from  this  cause,  up  to  the  time  he 
published  his  article  on  "  The  Treatment  of  Epithelioma  of  the  Cervix 
Uteri,"  in  1879.    (Am.  Journ.  Obstet.,  vol.  xii.  No.  iii.  p.  475.) 

C.  H.  Moore  reported  in  the  Lancet  (1864,  ii.  p.  428)  a  case  treated 
unsuccessfully  for  diarrhcea,  which,  on  post-mortem  examination,  was 
found  to  have  a  communication  between  the  vagina  and  the  small  intestine 
as  high  as  the  jejunum.  "  Cancerous  disease  had  traversed  the  adhesions, 
and  by  ulceration  made  an  opening  from  the  vagina  into  the  bowel." 

Pelvic  abscess  may  occasion  the  lesion,  the  pus  opening  into  the  ali- 
mentary and  genital  canals.  Fritsch  (Diseases  of  Women,  N.  Y.  1883, 
p.  283)  offers  the  following  explanation  of  the  manner  in  which  the  intes- 
tinal perforation  occurs  in  such  cases: — 

"The  inflamed,  paralytic  portion  of  the  intestine  depends  into  the  abscess 
cavity.  Some  feces  remain  behind  in  the  dependent  portion.  The  after-coming 
fecal  masses  force  that  portion  more  and  more  outward,  i.  e.,  into  the  abscess, 
solution  of  continuity  occurs,  and  the  old  fecal  fragments  drop  into  the  abscess 
cavity.  Thereby  the  contents  become  ichorous,  fever  ensues,  the  wall  of  the 
abscess  becomes  inflamed,  and  perforation  outward  or  into  an  adjoining  organ 
follows ;  gas,  fetid  pus,  and  a  few  old  fecal  fragments  are  evacuated." 

Difficult  labor  acts  as  a  cause  in  several  ways.  The  lesion  may  follow 
quickly  after  parturition,  as,  for  instance,  a  rupture  of  the  genital  canal 
would  allow  the  escape  of  a  loop  of  intestine  through  the  rent,  and  its 
subsequent  sloughing  would  form  a  fistula.  Secondly,  and  more  remotely, 
it  may  be  produced  by  the  occurrence  of  a  puerperal  cellulitis,  abscess, 
and  perforation  in  both  directions  as  mentioned  above.  M.  Demarquay 
gives  an  example  of  the  lesion  following  shortly  after  labor.  (Gaz.  Med. 
de  Paris,  1867,  xxii.  p.  341.)  A  long  and  tedious  labor  was  ended  by 
forceps  extraction.  After  the  fifth  day,  fecal  matter  began  to  pass  from 
the  vagina,  and  Avas  very  much  increased  in  amount  about  three  hours 
after  eating.  Examination  showed  that  the  discharge  came  through  the 
os  uteri,  and  by  passing  the  finger  into  the  cavity  of  the  womb  the  fistula 
could  be  felt  upon  the  anterior  face  of  the  uterus  at  the  union  of  the  body 
with  the  neck. 


390 


Fry,  Intestino-vaginal  Fistula. 


[April 


A  case  due  to  cellulitis  soon  after  confinement,  and  illustrating  the 
amount  of  suppuration  that  may  take  place,  is  reported  by  George  Cur- 
sham,  M.D.,  in  the  London  Medical  Gazette  (1834,  xiii.  p.  943).  The 
woman  died  with  symptoms  indicative  of  a  pelvic  abscess,  and  had  a  puri- 
form  discharge  from  her  vagina.  Post-mortem  examination  revealed  a 
large  cavity  in  the  right  iliac  fossa  filled  with  putrid  matter  and  coagu- 
lated blood.  The  psoas  and  iliac  muscles  were  almost  entirely  destroyed ; 
the  abscess  had  followed  the  course  of  the  former  muscle  and  burrowed 
into  the  thigh.  Parts  of  the  pelvic  bone  were  denuded,  and  a  portion  of 
the  capsular  ligament  of  the  hip-joint  was  also  destroyed.  The  intestine 
was  ulcerated  and  formed  a  free  communication  with  the  abscess,  so  that 
feculent  matter  had  passed  into  the  cavity.  The  abscess  extended  into 
the  cavity  of  the  pelvis  by  the  side  of  the  uterus,  and  a  communication 
was  formed  between  it  and  the  abscess  by  means  of  a  small  opening  a 
little  above  the  cervix.  The  arteries,  veins,  and  nerves  passing  to  the 
anterior  part  of  the  thigh  were  contained  in  the  abscess,  and  the  femoral 
and  iliac  veins  were  obliterated  by  firm  coagula. 

Fistulous  lesions  due  to  intestinal  affections  follow  the  symptoms  of  the 
antecedent  disease. 

The  following  being  one  of  the  inexplicable  cases,  I  feel  warranted  in 
giving  the  history  more  in  detail  than  would  otherwise  be  necessary. 

Mrs.  A.  E.  B.,  white,  twenty-eight  years  of  age,  was  born  in  Pennsyl- 
vania. With  the  exception  of  an  attack  of  typhoid  fever  in  1874,  she 
has  always  enjoyed  excellent  health.  Married  when  eighteen  years  old, 
but  has  never  been  pregnant.  Menstruation  began  when  fourteen,  was 
regular  and  painless  until  the  fall  of  1879. 

In  September,  1878,  she  was  taken  with  the  first  of  a  series  of  attacks, 
which  recurred  every  few  months.  They  consisted  of  pain  in  the  bowels  and 
of  nausea,  accompanied  by  constipation.  She  was  treated  for  neuralgia  of 
the  womb.  At  the  end  of  twelve  months  her  catamenia  failed  to  appear, 
and  from  that  time  the  attacks  became  more  frequent  and  violent. 

Two  months  later  (November,  1879)  her  abdomen  commenced  to  swell, 
and  she  noticed  a  "  fluttering"  in  her  left  side.  Was  also  greatly  annoyed 
by  frequent  and  painful  micturition.  These  symptoms  gave  rise  to  a  diag- 
nosis of  pregnancy  (extra-uterine?)  by  her  attending  physician.  Having 
continued  to  grow  worse,  she  was  obliged  to  keep  her  bed  for  two  or  three 
wreeks.  Had  constant  vomiting  and  severe  abdominal  pain,  with  consti- 
pation, in  spite  of  purgatives  by  mouth  and  injections  by  rectum.  Success 
after  several  weeks  brought  a  discharge  of  feculent  matter,  and  with  it 
the  relief  of  pain  and  vomiting.  During  the  succeeding  winter  she  had 
nausea  at  times,  and  some  abdominal  pain  with  diarrhoea  and  constipation 
alternating. 

In  April,  1880,  her  menses  returned  in  profuse  amount,  after  seven 
months'  absence,  and  her  attending  physician  thought  premature  labor 
threatened.  Her  abdomen  returned  to  its  natural  size.  It  had  continued 
to  enlarge  during  those  months,  and  was  then  as  prominent  as  it  should 
have  been  at  a  corresponding  stage  of  pregnancy. 

In  June  her  physician  left  the  city  for  several  weeks,  and  anticipating 
her  accouchement  at  an  early  day,  advised  that  she  should  call  in  a  certain 


1885.] 


Fey,  Intestino-vaginal  Fistula. 


391 


physician  living  near  by  in  case  the  event  came  off  in  his  absence.  She,  it 
may  be  stated,  had  all  along  questioned  the  opinion  of  pregnancy.  In  a 
few  days  she  was  seized  with  cramps  in  her  abdomen  of  more  than  usual 
severity,  and  called  in  the  other  doctor.  That  gentleman  expressed  doubt 
concerning  the  existence  of  pregnancy,  and  administered  an  anodyne,  which 
relieved  her  in  a  few  days. 

During  the  next  year  she  avoided  medical  advice,  and  managed  to 
attend  her  household  duties,  although  far  from  well.  Abdominal  pain  and 
bearing-down  sensations  were  complained  of,  the  "fluttering"  was  felt  in 
the  left  side,  and  exercise  produced  pain  on  that  side,  w7ith  a  numbness 
down  the  corresponding  limb. 

Nothing  noteworthy  occurred  until  Thursday,  June  9th,  1881,  when  a 
constipated  condition  of  the  bowels,  which  had  lasted  five  days,  was 
followed  by  a  severe  attack  of  cramps.  Anodynes  seemed  powerless  to 
relieve  her  of  the  agony.  Calomel  and  opium  were  administered  on  Fri- 
day, Saturday,  and  Sunday.  Sunday  and  Sunday  night  frequent  rectal 
injections  of  soap  and  water  were  given,  but  all  without  accomplishing 
their  purpose.  Monday  she  commenced  to  vomit  stercoraceous  matter? 
and  about  every  half  hour  a  washbasinful  of  thin  fluid  matter  was  ejected,1 
dark  green  in  color,  containing  some  lumps,  and  having  a  very  offensive 
odor.  Pain  was  relieved  when  the  vomiting  began.  In  the  evening  a 
»  consulting  physician  was  called  in.  A  blister  was  applied  to  the  epigas- 
trum,  flaxseed  poultices  put  over  the  abdomen,  the  calomel  given  without 
opium,  and  a  solution  of  carbolic  acid  ordered  internally.  Having  had  no 
nourishment  since  the  beginning  of  the  attack,  enemata  of  beef-tea  were 
given.  Monday  night  she  did  not  vomit  so  often.  Tuesday  vomited  ster- 
coraceous matter  four  or  five  times,  but  of  less  amount  and  more  fluid 
character.  At  6  P.  M.  of  that  day  she  felt  slightly  better,  and  small  quan- 
tities of  beef-tea  and  chicken  broth  were  taken  by  mouth.  Wednesday, 
7  A.  M.,  she  had  a  small  stool  of  dark  and  well-formed  pieces  of  feces, 
and  during  the  day  two  or  three  more  movements  were  passed.  Vom- 
iting ceased ;  improved  slowly  the  next  few  days  ;  bowels  acted,  but  the 
abdominal  pain  did  not  entirely  leave. 

The  following  Monday  (20th),  the  pain  increased,  and  each  paroxysm 
was  accompanied  by  gurgling,  while,  at  the  same  time,  the  peristaltic 
motion  of  the  intestines  was  plainly  visible,  causing  the  abdominal  wall  to 
rise  and  fall  with  a  vermicular-like  movement.  During  that  and  the  first 
half  of  the  succeeding  week,  the  pain,  the  gurgling,  and  visible  peristaltic 
movement  of  the  intestines  kept  up.  She  had  a  stool  nearly  every  day ; 
it  was  painful,  accompanied  by  tenesmus,  and  contained  blood  and  mucus. 

August  1st  she  suffered  an  aggravation  of  the  pain,  and  her  attending 
physician  being  absent  from  the  city  I  was  called  to  see  the  case.  Intend- 
ing only  to  temporize,  and  without  obtaining  a  history  of  her  illness,  I 
gave  a  hypodermic  injection  of  morphia,  directed  hot  flaxseed  poultices  to 
be  applied  over  the  abdomen,  and  left  an  opiate  to  be  taken  by  mouth. 
She  was  relieved  for  the  time,  but  on  the  night  of  the  3d  I  was  again  sent 
for,  and  asked  to  take  charge  of  the  case,  owing  to  the  continued  absence 

1  I  would  be  loth  to  accept  this  statement  without  due  allowance  for  exaggeration 
if  I  had  not  before  witnessed  the  enormous  quantities  of  intestinal  fluid  and  bilious 
matters  that  may  be  vomited  in  cases  of  obstruction  of  the  small  intestine.  The 
patient  and  her  husband  are  very  intelligent  persons,  and  remember  the  details  of  her 
sickness  so  well  that  I  have  had  little  difficulty  in  obtaining  this  history. 


392 


Fry,  Intestino-vaginal  Fistula. 


[April 


of  her  former  physician.  Pain,  gurgling,  and  stercoraceous  vomiting  had 
set  in.  When  I  arrived  she  was  in  the  act  of  vomiting  liquid  feces  of  a 
most  disagreeable  odor.  There  were  pain,  gurgling,  tenesmus,  and  bloody 
and  mucous  stools.  Examination  per  rectum  revealed  therein  the  pres- 
ence of  invaginated  bowel.  The  patient  was  placed  in  the  genu-pectoral 
position,  and  about  two  quarts  of  tepid  water  were  injected  into  the  bowel. 
She  was  kept  in  that  position  about  five  minutes,  when  pain  and  the  urgent 
desire  to  expel  the  fluid  made  it  necessary  for  her  to  use  the  chamber. 
The  clyster  was  forcibly  returned  discolored  with  feculent  matter.  The 
finger  passed  into  the  rectum  then  failed  to  reach  any  intussuscepted 
bowel.  Much  relief  was  experienced,  and  a  hypodermic  injection  of  mor- 
phia gave  an  uninterrupted  sleep  for  the  rest  of  the  night.  For  one  week 
following  large  rectal  injections  of  tepid  water  were  given,  morning  and 
night,  with  the  patient  in  knee-chest  position.  She  also  had  natural 
movements  from  the  bowels  daily.  Pain  was  relieved;  the  visible  peri- 
stalsis had  disappeared,  and  the  gurgling  tenesmus  and  dysenteric  stools 
were  absent.  She  was  very  much  emaciated,  but  improved  sufficiently  to 
leave  the  city  on  the  15th  of  September  for  a  visit  to  Pennsylvania. 
During  the  month  of  August,  and  up  to  the  time  of  leaving  Washington 
in  September,  the  large  enemata  had  been  administered  at  irregular  inter- 
vals. She  had  had  nausea  and  occasional  attacks  of  vomiting,  and  twice 
the  contents  of  the  ejected  matter  were  stercoraceous.  Pain  and  bor- 
borygmus  had  come  on  at  intervals,  but  the  dysenteric  symptoms  were 
relieved.  Liquid  diet  only  had  been  allowed.  Opium  and  bismuth  had 
been  administered  when  necessary.    Purgatives  were  avoided. 

The  patient  remained  away  one  month,  and  was  greatly  improved.  Until 
her  next  attack  of  sickness  she  had  a  good  appetite  and  digestion,  no 
nausea,  and  had  regular  actions  from  the  bowels.  Her  complaints  were 
irregular  and  scanty  menstruation,  bearing-down  sensations,  and  pain  in 
the  left  side  and  corresponding  limb  increased  by  exercise.  Examination 
revealed  the  uterus  in  its  normal  position. 

In  June*  1882,  she  had  an  attack  that  resembled  pelvic  cellulitis  of  the 
left  side,  which  confined  her  to  bed  one  month. 

August  6th  her  troubled  existence  was  further  made  miserable  by  a 
return  of  the  old  symptoms  of  intestinal  obstruction.  The  rectal  injec- 
tions were  repeated,  and  for  a  time  were  administered  through  a  long  rectal 
bougie.  Examination  per  vaginam  detected  for  the  first  time  the  pres- 
ence of  a  fluctuating  tumor  about  as  large  as  a  hen's  egg.  It  was  situated 
on  the  left  side  of,  and  separate  from,  the  uterus.  In  addition  to  the  pain 
and  vomiting  she  had  frequent  desires  to  urinate,  associated  with  straining 
efforts.  These  symptoms  kept  up  with  varying  degrees  of  intensity,  and 
the  tumor  increased  sensibly  in  size  until  at  the  time  I  left  the  city,  in 
September,  for  several  weeks'  vacation,  it  had  attained  the  dimensions  of 
an  ordinary  sized  orange.  When  I  returned  the  patient  had  left  home  for 
a  ti'ip,  and  I  saw  nothing  further  of  the  case  until  January,  1883.  She 
then  called  at  my  office,  and  I  learned  that  she  had  remained  away  one 
month  ;  that  the  abdominal  pains  and  bladder  irritation  had  continued  to 
trouble  her  until,  in  the  latter  part  of  December,  while  walking  the  floor 
in  a  paroxysm  of  pain,  she  suddenly  felt  something  break.  The  sensation 
was  accompanied  by  a  discharge  from  the  vagina  of  about  a  pint  of  pus 
and  blood  having  an  intensely  foul  odor.  For  a  time  she  was  relieved  of 
pain  and  irritation  of  the  bladder,  but  they  occasionally  returned  in  lesser 
degrees,  and  she  has  since  then  been  subject  to  slight  vaginal  discharge. 


1835.] 


Fry,  Intestino-vaginal  Fistula. 


393 


I  made  an  appointment  to  call  and  examine  herfor  the  purpose  of  ascer- 
taining whether  the  tumor  had  disappeared,  but,  in  the  mean  time,  was 
summoned  to  her  house  on  account  of  a  severe  attack  of  pain.  The  finger 
introduced  into  the  vagina  revealed  a  bagging  of  the  mucous  membrane  in 
front  of  the  cervix,  and  some  swelling,  but  no  well-defined  tumor,  to  the 
left  of  the  uterus.  A  teat-like  protuberance  was  situated  on  the  anterior 
wall  of  the  vagina,  in  the  median  line  and  about  three-quarters  of  an  inch 
below  its  junction  with  the  cervix.  A  speculum  was  introduced,  and  by 
further  examination  the  apex  of  the  projection  was  found  to  be  perforated 
by  an  opening  just  large  enough  to  admit  a  small  probe.  The  next  day, 
with  the  assistance  of  Dr.  J.  A.  Tarkington,  the  patient  was  placed  in 
Sims's  position,  and  I  enlarged  the  opening  with  a  probe-pointed  bistoury. 
Some  discharge  followed,  with  nothing  peculiar  to  attract  my  attention, 
except  its  disagreeable  odor.  The  following  day  I  found  the  patient  com- 
fortable. She  had  had  considerable  discharge  during  the  night,  and  the 
cloths  taken  from  her  presented  the  peculiar  yellow  discoloration  of  bile. 
I  passed  a  Xo.  10  gum  catheter  into  the  opening,  and  the  discharge  that 
ran  through  it  could  not  have  startled  me  more  had  I  tapped  her  gall- 
bladder. It  looked  like  pure  yellow  bile.  One  quart  of  warm  carbolized 
water  was  injected  through  the  tube  (allowing  it  to  run  out  as  it  was  thrown 
in),  with  the  effect  of  being  returned  discolored  yellow,  and  at  times  dark 
muddy,  and  containing  shreds  of  tissue  and  pieces  of  feculent  matter. 
The  odor  was  intensely  disagreeable  and  feculent.  These  injections  were 
repeated  daily  for  two  or  three  weeks,  then  every  other  day  for  several 
months,  and  finally  the  intervals  wTere  increased  to  three  or  four  days. 
The  catheter  when  pushed  through  the  vaginal  opening  could  be  made, 
without  effort,  to  penetrate  ten  or  twelve  inches  within  the  fistula.  She 
was  made  comfortable,  and  suffered  no  further  pain  except  once  in  Septem- 
ber, when  I  allowed  seven  days  to  elapse  before  washing  out  the  cavity.  The 
returning  fluid  always  brought  feculent  matter,  with  sometimes  a  more  dis- 
agreeable odor  than  at  others.  At  each  menstrual  epoch  for  some  months 
succeeding  the  opening  of  the  fistula  the  discharge  would  increase  in  quan- 
tity and  assume  very  irritating  qualities.  It  would  become  more  bilious 
and  acrid  at  such  times,  irritating  the  vagina  and  external  parts  and 
causing  them  to  swell  and  burn.  The  only  relief  she  could  procure  was 
by  frequent  vaginal  injections  of  hot  soothing  liquids.  This  seldom 
occurred  except  at  menstrual  periods  which  were  accompanied  by  scant 
flow  of  blood.  Often  the  discharge  through  the  fistula  was  observed  to  be 
increased  about  an  hour  after  a  meal,  and  it  was  particularly  apt  to  be  of 
the  acrid,  bilious  character  if  any  greasy  food  had  been  partaken  of.  At 
some  washings  particles  of  food  would  be  brought  away,  such  as  pieces  of 
meat,  and  the  yellow  of  hard-boiled  e^g.  The  seeds  of  fruit  and  toma- 
toes,  and  the  pulp  tissue  of  orange,  were  often  recognized.  In  fact  I  could 
generally  give  a  tolerably  accurate  description  of  the  bill  of  fare  which 
had  constituted  the  previous  meal  by  means  of  the  contents  of  the  water 
returned  by  injection.  Occasionally  such  refuse  would  accumulate  in 
sufficient  quantity  to  dam  back  the  flow  through  the  fistula,  and  cause  pain 
until  relieved  by  an  injection.  During  these  washings  she  often  declared 
that  she  could  feel  the  water  run  up  into  her  bowels  on  the  left  side,  and 
it  is  a  significant  fact  that  frequently  afterwards  she  would  feel  a  desire  to 
have  a  movement,  and  on  sitting  upon  the  chamber  would  pass  a  thin  fluid 
stool. 


394 


Frt,  Intestino-vaginal  Fistula. 


[April 


Her  general  health  improved  very  much,  her  appetite  became  good, 
bowels  regular;  she  had  no  abdominal  pain,  and  no  further  trouble  with 
the  left  side  or  leg. 

The  amount  of  discharge  through*  the  fistula  has  been  gradually  lessen- 
ing, until  at  present  I  do  not  wash  it  out  but  once  in  three  or  four  weeks. 
Also,  much  less  solid  debris  is  passed.  For  these  reasons  I  am  encouraged 
to  believe  that  the  proximal  opening  of  the  fistula  is  undergoing  a  gradual 
cicatricial  contraction. 

Her  health  is  good,  and  she  attends  altogether  to  her  own  marketing  and 
household  atfairs,  and,  in  fact,  is  comparatively  little  inconvenienced  by 
her  trouble. 

Remarks. — I  have  stated  my  inability  to  unravel  this  pathological 
knot,  and  the  several  views  that  occur  to  my  mind  are  merely  conjectural 
explanations  that  have  no  proof  to  sustain  them.  In  fact,  I  can  scarcely 
see  how  anything  short  of  a  post-mortem  examination  would  have  revealed 
the  sequence  of  pathological  events.  More  particularly  is  this  true  of 
that  period  of  ill  health  preceding  the  intestinal  obstruction  that  occurred 
in  June,  1881 — a  period  of  several  years  that  was  marked  by  nausea, 
abdominal  pains,  and  enlargement,  suppression,  and,  later,  irregular  men- 
struation, and  bearing-down  sensations.  The  cause,  nature,  and  situa- 
tion of  the  obstruction  are  equally  involved  in  obscurity ;  its  relief  was 
followed  by  pain,  gurgling,  and  visible  peristaltic  movement  of  the  intes- 
tines, symptoms  indicating  that  the  calibre  of  the  gut  was  not  restored. 
Two  months  later  the  condition  culminated  in  well-marked  intussusception. 

The  character  of  the  discharge  through  the  fistula,  and  its  increase  as 
soon  as  one  hour  after  eating,  indicate  that  the  intestinal  perforation  is 
situated  in  the  small  intestine.  It  is  evident  that  the  tissues  of  the  bowel 
at  that  point  were  so  much  impaired  by  the  lesion  causing  the  obstruction 
and  intussusception,  or  by  the  intussusception  itself,  that  perforation  oc- 
curred, and  the  contents  of  the  alimentary  canal  escaped.  It  is  probable 
that  a  local  peritonitis  caused  adhesions  to  form  between  the  visceral  and 
parietal  peritoneum  at  the  site  of  the  perforation,  and  prevented  the 
escape  of  feculent  matter  into  the  peritoneal  cavity.  The  sinus  then 
burrowed  its  way  in  the  intermuscular  cellular  tissue,  most  likely  in  the 
region  of  the  psoas,  and  finally  reached  the  left  iliac  fossa.  It  will  be 
remembered  that  the  reduction  of  the  invaginated  bowel  only  relieved  the 
immediate  dangers.  For  ten  months  afterwards  she  suffered  pains  in  the 
left  side  and  limb,  and  bearing-down  sensations,  increased  by  exercise. 
That  period  would  correspond  to  the  time  when  the  sinus  was  making  its 
way  down  to  its  vaginal  termination.  Pelvic  cellulitis,  abscess,  and  rup- 
ture into  the  vagina  would  complete  the  conjectural  picture  of  the  forma- 
tion of  the  fistula. 

The  diagnosis  of  intestino-genital  fistulas  is  made  by  an  examination  of 
the  discharges  passed  per  vaginam.    Sometimes  the  condition  is  not  sus- 


1885.] 


Fry,  Intestino-vaginal  Fistula. 


395 


pected  until  after  death,  owing  to  the  infrequent  occurrence  of  such 
lesions,  and  to  the  severity  of  the  accompanying  symptoms  directing 
attention  to  other  parts.  A  case  has  .already  been  mentioned  that  was 
treated  for  diarrhoea,  and  the  fistula  was  unexpectedly  discovered  at  the 
post-mortem  examination.  Dr.  T.  G.  Thomas,  of  Charleston,  reports  a 
case  that  was  thought  to  be  one  of  tubercular  ulceration  of  the  intestines. 
{Charleston  Med.  Journ.,  1854,  viii.  639.)  The  treatment  had  little 
influence  over  the  disease ;  she  became  very  much  emaciated,  and  died 
three  months  from  the  beginning  of  the  attack.  During  the  last  month 
of  her  life  she  had  a  profuse  leucorrhcea ;  the  discharge  was  thick,  puru- 
lent, and  offensive.  The  appearance  of  the  discharge  was  like  ordinary 
leucorrhcea,  and  presented  nothing  calculated  to  arouse  suspicion  of 
fistulous  opening  except  possibly  the  smell 

Autopsy  revealed  .  .  .  "  a  membranous  band,  apparently  a  part  of  the  right 
lateral  ligament,  extending  from  the  caput  coli  to  the  upper  part  of  the  vagina, 
which,  upon  raising  the  parts,  was  sundered,  and  discharged  a  clot  of  coagulated 
blood.  Uterus  free  from  disease  ;  cavity  enlarged,  and  tissue  relaxed  and  pale. 
Near  the  junction  of  the  vagina  with  the  uterus  there  existed  a  fistulous  orifice, 
connected  with  the  band  above  mentioned,  and  through  which  a  probe  could  be 
passed  with  much  ease  into  the  csecum.  The  ca?cum  was  filled  with  blood,  as 
was  also  the  ileum,  for  some  distance  along  its  extent ;  near  the  junction'  of  the 
appendix  vermiformis  with  the  caecum  there  appeared  an  orifice  similar  to  that  in 
the  vagina,  except  being  of  larger  size,  and  similarly  related  to  the  communicat- 
ing canal.  Neither  dysenteric  ulcerations  nor  tubercular  deposits  were  discovered 
in  any  part  of  the  intestines." 

Dr.  Thomas  concluded  that  the  diarrhoea  was  caused  by  the  opening  of 
an  abscess  of  the  uterine  appendages  into  the  colon,  and  that  the  leucorrhcea 
came  from  a  similar  perforation  and  discharge  into  the  vagina. 

The  prognosis  of  these  fistulas  is  very  grave,  particularly  of  the  uterine 
variety.  Death  is  due,  in  the  majority  of  cases,  to  the  accompanying 
disease,  while  in  some  it  is  the  result  of  chronic  suppuration,  of  pyaemia, 
septicaemia,  or  exhaustion.  The  affection  terminates  favorably  in  a  con- 
siderable number  of  cases.  Petit  quotes  a  case  that  was  cured  by  the 
woman  becoming  pregnant  and  giving  birth  to  a  full-term  child.  A.  T. 
Einbeck,  M.D.,  reported  a  case  of  spontaneous  cure  in  a  child  twelve 
years  of  age.  (St.  Louis  Cour.  Med.,  1880,  iv.  122.)  Pills  taken  by  the 
mouth,  and  feculent  matter,  were  passed  per  vaginam.  Very  little  can  be 
done  in  the  way  of  treatment  except  to  palliate  suffering.  Caustics  may 
be  useful  in  some  cases.  Laparotomy  and  closure  of  the  intestinal  opening 
by  suture  may  be  a  proper  procedure  in  cases  demanding  it. 
No.  819  Fourteenth  Street,  N.  W. 


396 


Gleitsmann,  Laryngeal  Hemorrhage. 


[April 


Article  VI. 

Laryngeal  Hemorrhage.  By  J.  W.  Gleitsmanx,  M.B.,  Surgeon  to  the 
German  Dispensary,  and  Assistant  to  the  New  York  Polyclinic,  Throat  and 
Ear  Department,  New  York. 

The  name  laryngeal  hemorrhage  is  used  for  a  variety  of  affections 
which  differ  widely  in  regard  to  cause,  nature  of  the  disease,  and  severity 
of  the  symptoms,  and  have  in  common  only  the  effusion  of  blood  into  some 
part  of  the  larynx.  Investigation  will  be  facilitated  by  first  ascertaining 
whether  the  effusion  took  place  on  the  free  surface  of  the  mucous  membrane, 
or  into  the  submucous  tissue.  Submucous  hemorrhages  are  often  grave  in 
character,  and  in  the  majority  of  cases  due  to  some  extrinsic  cause,  trauma, 
for  instance.  Surface  bleeding  arises  from  a  number  of  causes,  of  which 
we  may  mention  foreign  bodies,  ulcerations  subsequent  to  syphilis,  cancer, 
haemophilia,  further  catarrhal  conditions,  and  sometimes  from  no  assignable 
cause.  The  name,  laryngitis  hasmorrhagica,  is  generally  applied  on  the 
continent  to  hemorrhages  into  the  interior  of  the  larynx,  which  do  not 
originate  from  any  lesion,  but  are  considered  an  independent  malady, 
generally  connected  with  catarrhal  laryngitis.  Although  it  cannot  be 
denied  that  the  extravasation  of  blood  is  in  many  instances  a  symptom, 
however  rare,  of  an  existing  cause,  there  are  undoubtedly  cases  in  which 
hemorrhages  occur  without  previous  disease.  Inasmuch  as  the  term  laryn- 
geal hemorrhage  is  applicable  to  such  a  variety  of  different  conditions,  it 
seems  advisable,  in  the  opinion  of  the  writer,  to  retain  the  name  laryngitis 
hemorrhagica,  and  to  designate  by  it  those  effusions  of  blood  on  the  free 
surface,  or  under  the  epithelium  of  the  mucous  membrane,  which  are  of  a 
so-called  idiopathic  character,  and  not  due  to  any  constitutional  disease  or 
traumatic  origin. 

A  case  of  this  nature  recently  came  under  my  observation.  Patient, 
male,  25  years  of  age,  gave  the  following  history  :  His  sickness  began 
with  hoarseness,  which  gradually  increased  within  one  week  to  complete 
aphonia,  lasting  two  days.  At  the  same  time  dyspnoea  set  in,  which  was 
greater  in  the  morning  and  evening  than  during  the  rest  of  the  day.  Four 
days  later,  November  23,  1884,  thirteen  days  after  the  onset,  he  expec- 
torated blood  the  first  time  when  walking  home  to  dinner.  No  unusual 
exertion  or  excitement  preceded  the  bleeding,  which  this  time,  as  well  as 
later,  occurred  without  previous  cough,  and,  with  but  one  exception,  at  the 
same  hour.  The  quantity  of  blood  lost  was  always  small,  and  amounted 
to  about  half  a  teaspoonful.  After  the  second  hemorrhage  the  next  day, 
he  sought  medical  aid. 

Patient  is  a  short-set,  robust  man,  of  fair  intelligence,  with  muscles  well 
developed,  and  very  little  superfluous  adipose  tissue.  He  appears  to  be 
about  five  feet  seven  inches  high,  weighs  160  pounds,  and  has  a  good  family 
record.  Five  years  ago  he  suffered  from  malaria  for  eight  months  at  his 
home  (Galizia),  but  otherwise  was  always  well.  He  came  to  New  York 
City  in  1882,  and  is  at  present  making  button-holes.  His  workshop  is 
well  ventilated;  his  residence,  aside  from  tenement  life,  healthy. 


1885.] 


Gleitsmann,  Laryngeal  Hemorrhage. 


397 


Physical  examination  of  the  chest  and  other  organs  revealed  nothing 
abnormal.  The  laryngoscopy  eal  mirror  showed  symptoms  of  intense  catarrh, 
reddish-gray  discoloration  of  the  vocal  cords,  and  general  congestion  and 
turgescence  of  the  mucous  membrane,  especially  of  the  ventricular  bands, 
which  thereby  greatly  interfered  with  inspection  of  the  cords.  At  the 
junction  of  the  anterior  and  middle  third  of  the  left  band  was  a  bleeding 
spot  of  the  size  of  a  pin's  head,  from  which  the  blood  could  be  seen  oozing 
after  being  mopped  up  with  the  cotton  carrier.  Dark  coagula  were  visible 
along  the  whole  free  border,  and  also  below  the  left  cord. 

The  following  day  his  dyspnoea  increased,  but  he  had  not  expectorated 
blood  since  the  previous  day.  The  greater  part  of  both  ventricular  bands 
was  covered  with  crusts  of  coagulated  blood,  which  were  firmly  adherent, 
and  both  cords  presented  the  same  appearance  as  the  left  one  did  the  day 
before.  This  picture  was  the  acme  of  the  disease,  and  henceforth  his 
symptoms  became  less  aggravating.  After  another  slight  hemorrhage  the 
next  day,  only  the  posterior  surface  of  the  epiglottis  and  the  anterior  part 
of  the  ventricular  bands  were  covered  with  coagula.  He  spit  blood  twice 
more  on  the  two  following  days,  the  last  time  on  the  sixth  day  after  the 
first  attack.  The  dyspnoea  and  congestion  of  the  mucous  membrane  gradu- 
ally decreased,  and  when  he  ceased  attendance  on  the  tenth  day,  Decem- 
ber 2d,  his  voice  was  better,  his  breathing  free,  and  his  general  condition 
good.  As  there  were  at  no  time  any  threatening  symptoms  present,  the 
treatment  consisted  simply  in  resolvent  inhalations  and  topical  applications 
of  perchloride  of  iron  and  nitrate  of  silver  alternately.  When  seen  eight 
weeks  later,  he  was  as  well  and  hearty  as  ever. 

From  the  description  it  will  be  seen  that  this  case  ranks  amongst  those 
of  laryngitis  hemorrhagica,  as  defined  above.  The  literature,  as  far  as  ac- 
cessible to  the  writer,  is  not  so  scant  as  it  is  generally  supposed,  and  would 
assume  considerable  proportions  if  all  cases  observed  were  published. 
Semeleuer1  was  the  first  to  speak  of  dark-red  vocal  cords  and  a  fresh  co- 
agulum  on  the  anterior  third  of  the  right  ventricular  band  in  a  man  who 
the  day  before  had  violent  vomiting  after  too  hearty  a  meal,  and  streaks 
of  blood  in  his  expectoration.  Another  man  with  the  same  symptom  per- 
sisting for  three  weeks  had  a  small  coagulum  on  the  left  band. 

Lewin's2  patient  had  croupy  cough,  and  great  dyspnoea  at  intervals.  A 
bloody  effusion  extended  over  both  vocal  cords.  A  similar  condition  was 
present  in  a  lady  patient,  who  also  spit  blood.  Lewin,3  besides,  relates  a 
case  which,  although  not  properly  belonging  to  this  chapter,  is  interesting 
enough  to  be  briefly  stated.  An  American  medical  student,  previously 
accustomed  to  vigorous  outdoor  exercise,  devoted  himself  ardently  to  his 
studies.  Pie  acquired  a  cold,  followed  by  tickling  in  the  pharynx,  and 
repeatedly  coughed  up  small  quantities  of  blood.  The  lungs  were  declared 
intact  by  another  physician,  but  Lewin  found  the  anterior  tracheal  wall 
way  down  covered  with  bloody  mucus,  and  saw  how  a  small  stream  of 
blood  appeared  at  times  on  the  posterior  part  of  the  larynx,  gradually  ex- 

1  Semeleder,  F.,  die  Laryngoscopie,  Wien,  Braumueller,  1863,  p.  33. 

2  Lewin,  J.,  die  Inhalationstherapie,  ii.  edition,  Berlin,  Hirschwald,  1865,  p.  328. 

3  Lewin,  1.  c.  p.  310. 

No  CLXXVIIL— April,  1885.  26 


398 


Gleitsmann,  Laryngeal  Hemorrhage. 


[April 


tending  to  the  upper  part  of  the  interarytenoid  space.  He  concluded  that 
the  source  of  the  bleeding  was  in  the  bronchi,  and  expressed  his  fear  that 
it  was  the  forerunner  of  constitutional  disease.  A  few  months  later  the 
patient  had  a  severer  hemorrhage,  and  symptoms  of  incipient  phthisis 
developed. 

NavratiPs1  case  occurred  in  winter,  when  suddenly  very  cold  weather 
set  in.  A  dark-brown  layer  covered  the  cords,  which,  after  removal  of 
the  extravasated  blood,  appeared  red  and  turgescent.  Several  local  appli- 
cations made  it  finally  disappear. 

Mandl2  saw  effusion  of  blood  from  the  ventriculi  Morgagni  in  an  aged 
lady.  Tobold3  mentions  spontaneous  bleeding  on  the  border  of  the  epi- 
glottis and  surface  of  the  cords  in  a  healthy  man,  and  a  bleeding  vessel 
on  the  right  cord  in  a  delicate  government,  clerk,  both  patients  being  sub- 
ject to  preceding  catarrhal  laryngitis.  Concentrated  solution  of  alum  was 
the  treatment  adopted. 

Fraenkel's4  case  is  the  most  instructive  one  on  account  of  the  quantity 
of  blood  lost,  and  of  the  duration  of  the  disease.  A  woman  in  the  last 
month  of  her  fourth  pregnancy,  who  had  daily  vomiting,  but  otherwise 
was  healthy,  complained  of  hoarseness  and  dyspnoea,  and  expectorated 
blood  four  days  before  seeking  advice.  The  mucous  membrane  of  the 
larynx  was  considerably  swollen,  especially  on  the  posterior  wall ;  it  was  of 
deep-red  color,  the  vocal  cords  of  blackish  redness.  Small  dark  tumors 
adhered  to  the  cords  and  were  seen  below  them,  hiding  the  trachea  from 
view.  The  distress  of  breathing  ceased  as  soon  as  small  dark  blood-crusts 
were  expectorated,  and  then  parenchymatous  bleeding  from  the  cords  and 
posterior  wall  could  distinctly  be  seen.  Fraenkel  had  occasion  to  ex- 
amine the  patient  during  one  of  her  attacks,  changing  from  comparative 
ease  to  severe  dyspnoea  and  relief,  as  soon  as  the  crusts  were  coughed  up. 
For  several  days  these  symptoms  recurred  every  half  hour,  and  four  weeks 
after  the  first,  the  patient  had  the  last  hemorrhage.  The  amount  of  blood 
lost  was  once  a  half,  and  at  another  time  a  whole,  cupful.  After  her  con- 
finement the  bleeding  stopped,  but  the  catarrhal  symptoms  remained  for 
some  time  later.  It  may  be  stated  that  the  weather  was  extremely  incle- 
ment during  that  season. 

Boecker's5  patient  presented  similar  features — catarrh,  sanguineous  dis- 
charge one  week  before  examination,  and  the  same  appearance  of  the 
mucous  membrane  and  cords.  Dyspnoea  was  brought  on  only  by  forced 
inhalation ;  the  hemorrhage  yielded  to  treatment  after  several  days. 

1  Navratil,  E.,  Laryngologische  Beitrage,  Leipzig,  Zechel,  1871,  p.  18. 

2  Mandl,  L.,  Traite  pratique  des  maladies  du  larynx,  Paris,  Bailliere,  1872,  p.  644. 

3  Tobold,  A.,  Laryngoscopie  und  Kehlkopfkrankheiten,  Berlin,  Hirschwald,  1874, 
p.  142. 

*  Fraenkel,  B.,  Berliner  klinische  Wochenschrift,  No.  2, 1874. 
5  Boecker,  A.,  Berliner  klinische  Wochenschrift,  No.  15,  1874. 


1885.] 


Gleitsmann,  Laryngeal  Hemorrhage. 


399 


Boecker  used  inhalations  of  chloride  of  sodium,  whilst  Fraenkel  applied 
nitrate  of  silver  1  to  15,  and  1  to  30.  A  second  case  of  Boecker — extra- 
vasation of  blood  into  the  mucous  membrane  after  cauterization  of  an 
ulcer — cannot  well  be  classified  under  our  heading. 

Hartmann1  saw  bleeding  in  a  member  of  a  singing  society,  who  spit 
up  blood  of  a  florid  color  and  two  to  three  ounces  in  quantity  after  a 
rehearsal,  and  also  the  following  morning.  No  unusual  strain  of  the  voice 
or  catarrhal  symptoms  preceded  the  accident.  The  blood  was  oozing 
from  a  largely  ruptured  capillary  vessel  upon  the  upper  surface  about  the 
middle  of  the  left  ventricular  band,  and,  trickling  down  into  the  glottis, 
produced  paroxysms  of  dyspnoea,  cough,  and  expectoration.  The  applica- 
tion of  a  strong  solution  of  ferric  alum  to  the  seat  of  the  hemorrhage 
readily  controlled  the  bleeding. 

Wagner's2  patient  was  a  physician  who  had  several  profuse  hemor- 
rhages from  the  larynx  within  four  months.  When  first  examined  he  had 
general  hyperemia  of  the  mucous  membrane  ;  the  blood  came  from  the 
left  band  and  ventricle  posteriorly.  Repeated  examinations  of  the  chest 
gave  negative  results,  and  the  doctor  lived  to  become  an  active  worker  in 
the  profession. 

Mackenzie3  confines  himself  to  saying  that  he  met  with  a  few  cases, 
and  that  in  these  the  congestion  was  slight,  and  that  the  hemorrhage  almost 
always  resulted  from  some  violent  expiratory  effort,  such  as  coughing  or 
vomiting. 

Smith's4  patient  was  an  actor,  who  frequently  spit  blood  in  the  course 
of  fourteen  months — less  during  the  day,  more  during  and  after  the 
exertion  of  the  evening.  The  blood  was  seen  coming  from  the  right 
vocal  cord  near  its  attachment  to  the  vocal  process  of  the  arytenoid  carti- 
lage. A  solution  of  perchloride  of  iron  proved  effectual ;  but,  as  the 
patient  would  not  give  up  his  engagement,  and  as  the  exciting  cause 
remained,  treatment  was  abandoned. 

Effusion  of  blood  under  the  epithelium  of  the  left  cord  in  its  whole 
length  in  a  woman  with  pharyngo-laryngitis  was  seen  by  Schnitzler,5  who 
also  observed  extravasation  in  both  cords  in  a  girl  with  diphtheritic 
paralysis.  He  besides  mentions  hemorrhages  of  the  left  cords  occurring 
in  two  lady  singers  after  great  vocal  exertion,  returning  in  the  course  of 
three  years,  and  successfully  relieved  in  two  weeks  by  insufflations  of  ace- 
tate of  lead  and  nitrate  of  silver. 

1  Hartmann,  J.  H.,  Transactions  of  the  American  Laryngological  Association,  1879, 
p.  275. 

2  Wagner,  Clinton,  ibid.  p.  279. 

3  Mackenzie,  Morell,  Manual  of  Diseases  of  the  Throat  and  Nose,  vol.  i.  London, 
Churchill,  1880,  p.  268. 

4  Smith,  A.  H.,  Archives  of  Laryngology,  vol.  i.,  No.  1,  1880,  p.  65. 

5  Schnitzler,  L,  Wiener  medizinische  Presse,  No.  38,  1880. 


400 


Gleitsmann,  Laryngeal  Hemorrhage. 


[April 


Bettman1  describes  the  case  of  a  widow,  who,  five  clays  after  exposure 
to  a  draught,  spit  at  night  half  a  teacupful  of  blood  during  a  violent  cough. 
The  entire  laryngeal  and  tracheal  mucous  membrane  was  deep  red.  the 
vocal  cords  hyperaemie,  the  ventricular  bands  thickened  and  almost  livid 
in  color.  They  were  covered  with  fresh  and  dried  blood,  and  showed 
two  symmetrical  bleeding  spots  on  their  lateral  surfaces.  After  a  similar 
second  attack,  an  application  of  fused  nitrate  of  silver  and  benzoin  inhala- 
tions stopped  the  bleeding. 

Schaeffer2  observed  sanguinolent  expectoration  and  blood-crusts  on  the 
cords,  below  them,  and  also  in  the  whole  larynx  in  three  female  cooks, 
who,  exposed  to  rapid  changes  of  temperature,  had  intense  laryngitis, 
with  cough  and  dyspnoea.  The  fourth  patient,  a  robust  servant-girl, 
showed  dried  coagula.  extending  over  the  whole  larynx  down  to  the  upper 
part  of  the  trachea  ;  she  was  cured  within  six  days  by  internal  administra- 
tion of  iodide  of  potassium,  additional  to  insufflations  of  boracic  acid  and 
iodoform.  Schaeffer  ascribes  the  quicker  result  in  the  last  case  to  the 
iodide  of  potassium.  All  four  were  from  24  to  30  years  of  age,  and  had 
cessation  of  menses  during  their  sickness  ;  the  last  one  was  attacked  with 
the  bleeding  at  the  time  she  ought  to  have  menstruated  (vicarious  men- 
struation). 

Stepanow3  alludes  to  the  case  of  a  phthisical  girl  with  bloody  sputa, 
swelling  of  the  bands,  and  coagula  below  the  cords,  and  then  gives  the 
history  of  two  patients,  who.  according  to  him.  with  those  of  Fraenkel, 
Boecker,  and  perhaps  Lewin  alone,  can  be  called  true  cases  of  laryngitis 
hemorrhagica.  The  first  was  that  of  a  female  hospital  nurse,  who  caught 
a  severe  cold,  became  aphonic,  and  spit  a  tablespoonful.of  blood  in  bed  on 
the  third  day.  The  bleeding  was  always  of  the  same  quantity,  and  oc- 
curred either  daily  or  every  other  day.  When  examined  on  the  tenth 
day  the  cords  were  pale  red  :  dark,  thick  coagula  were  visible  along  the 
whole  length  of  their  lower  surface,  coalescent  at  the  anterior  angle.  Pig- 
ments of  nitrate  of  silver  made  the  coagula  disappear  after  four  or  five 
days,  but  several  relapses  occurred,  one  after  applying  electricity  on  ac- 
count of  diminished  tension  of  the  cords,  another  during  a  paroxysm  of 
cough  after  topical  treatment.  After  a  little  over  three  weeks  the  bleed- 
ing stopped,  and  two  weeks  later  the  catarrhal  laryngitis  also  disap- 
peared. The  other  patient  Stepanow  saw  only  once  ;  she  had  similar 
symptoms,  expectorated  blood  generally  in  the  morning  after  a  severe 
cough,  and  was  sick  over  one  month.  Jt  is  not  quite  evident  why  Stepa- 
now claims  the  name  laryngitis  haemorrhagica  for  his  two  cases  with  those 
mentioned  above,  and  quoted  by  him  exclusively.  He  lays  stress  on  the 
influence  of  sex  (female),  the  longer  duration  of  the  disease,  on  the  mild- 

1  Bettman,  J..  Chicago  Medical  Journal. and  Examiner,  August,  1882. 

2  Schaeffer,  M..  Deutsche  medicinische  Wochenschrift,  No.  2,  1883. 

3  Stepanow,  J.  M.,  Monatschrilt  lur  Ohrenheilkunde,  etc..  Xo.  1,  1884. 


1885.] 


Gleitsmann,  Laryngeal  Hemorrhage. 


401 


ness  of  catarrhal  symptoms  in  sqme  instances,  as  in  his  own  case,  which, 
by  the  way,  had  hoarseness  and  aphonia  before  bleeding,  and  on  the  origin 
of  the  hemorrhage  from  the  vocal  cords. 

If  the  term  laryngitis  hemorrhagica  has  to  be  narrowed  down  to  such 
limits,  our  synopsis  of  the  literature  will  show  that  some  cases  even  sur- 
pass Stepanow's  observation,  partly  in  duration,  partly  in  quantity  of  blood 
expectorated,  and  therefore  deserve  the  same  title. 

Ingalls1  calls  his  case  one  of  submucous  infiltration  of  blood  in  the  left 
vocal  cord,  but,  as  it  resembles  that  of  Schnitzler's  so  much,  it  is  included 
here.  The  patient,  a  merchant,  complained  of  sudden  hoarseness  and  dis- 
comfort in  the  larynx  one  morning,  and  on  examination  the  left  cord  was 
found  of  a  brownish-red  hue,  about  twice  its  normal  size.  Iodoform  powder 
and  cold  compresses  had  considerabty  improved  the  color  and  size  of  the 
cord  when  seen  two  days  later. 

With  a  view  of  ascertaining  to  some  degree  the  proportion  of  cases 
published  to  those  observed,  fifty-seven  circular  letters  were  addressed  to 
laryngologists  in  different  States.  It  was  also  deemed  desirable  to  learn 
the  opinion  of  the  profession  on  the  possible  relationship  between  laryn- 
geal hemorrhage  and  subsequent  pulmonary  phthisis.  To  these  inquiries 
twenty-five  answers  were  received,  which  are  herewith  thankfully  acknow- 
ledged. Twelve  observers  had  not  met  with  cases,  and  of  the  remaining 
thirteen  affirmative  answers,  eight  gave  special  data.  Two  of  these  are  re 
corded  (Smith,  Ingalls);  the  other  six  (Knight,  of  Boston,  Seiler,  Tauber, 
Lefferts,  Morgan,  Simrock)  gave  details  of  twenty-two  cases  of  hemor- 
rhages on  the  surface  of  the  mucous  membrane  in  different  parts  of  the 
larynx,  exclusive  of  those  due  to  traumatic  or  dyscrasic  agencies.  Only 
three  of  these  patients  had  subsequent  phthisis,  one  six,  another  eight 
months  after  the  laryngeal  bleeding.  The  general  tenor  of  the  replies 
was,  that  hemorrhage  from  the  larynx  can  be  regarded  as  a  precursor  of 
phthisis  in  exceptional  cases  only.  The  data  furnished  further  tend  to  sus- 
tain the  assertion  made  in  this  paper,  that  many,  if  not  the  majority,  of 
cases  are  not  published,  and  that  they  are  by  no  means  so  rare  an  occur- 
rence as  generally  supposed. 

Although  not  coming  strictly  within  the  scope  of  this  article,  there  are 
laryngeal  hemorrhages  which  are  of  sufficient  interest  to  the  laryngolo- 
gist  to  deserve  mention,  and  some  of  these  will  be  briefly  enumerated. 
Schroetter2  and  Schnitzler  saw  extravasation  of  blood  in  the  larynx  and 
trachea  in  morbus  maculosis  Werlhofii ;  and  Rethi3  describes  two  similar 
cases,  one  of  which  he  attributes  to  haemophilia.  Electricity  seems  to 
have  been  the  cause  of  a  relapse  in  Stepanow's  case  ;  and  Schroetter  saw 

1  Ingalls,  E.  F.,  Journal  of  the  American  Medical  Association,  No.  15,  1881. 

2  Schroetter,  L.,  Jahresbericht  der  Klinik  fur  Laryngoscopie.  Wien,  Braumueller, 
1871,  pp.  3  trad  4. 

3  Eethi,  L.,  Wiener  medizinische  Presse,  Nos.  36  und  37, 1884. 


402 


GrLlsiT s  mann j  Laryngeal  Hemorrhage. 


[April 


an  effusion  of  blood  on  the  cord  under  endolaryngeal  application  of  the 
same  agent.  The  latter  also  records  the  change  of  the  left  cord  to  an  in- 
tensely red  swelling  after  applying  a  two  per  cent,  solution  of  nitrate  of 
silver  to  the  larynx  of  a  gracile  lady.  Bettman  (/.  c.)  writes  of  a  gush  of 
blood  coming  from  a  longitudinal  cleft  of  a  papillomatous  excrescence  on 
the  posterior  laryngeal  wall  in  a  man  suspected  of  phthisis  ;  and  Schaeffer 
(/.  c.)  saw  a  blood  coagulum  covering  a  fissure  of  the  mucous  membrane 
of  the  incisura  inter-arytenoidea  in  a  girl  with  catarrhal  laryngitis  (cases 
of  Stoerk's  fissura  mucosa,  Virchow's  Archiv,  vol.  lx.  p.  274).  Instances 
of  hemorrhages  brought  on  by  foreign  bodies  or  ulcers  in  the  larynx  are 
of  no  uncommon  occurrence.  Of  the  former.  Gross1  says  :  after  swallowing 
foreign  bodies,  the  patient  throws  up  blood  sometimes.  The  quantity  is 
usually  very  small ;  now  and  then  however  it  amounts  to  several  ounces. 
(See  also  Hartman,  I.  c.)  Gibb2  had  a  lady  patient  afflicted  with  laryn- 
gitis from  syphilitic  dyscrasia.  She  spit  blood  of  bright  florid  color  three 
times  on  the  day  she  was  examined.  There  was  no  cough,  but  a  breach 
of  surface  of  very  intensely  red  color  in  the  mucous  membrane  above  the 
left  ventricle.  Tuerk3  relates  the  death  of  a  patient  from  an  erosion  of  the 
arteria  lingnalis,  caused  by  a  large  syphilitic  ulcer  at  the  right  extremity 
of  the  hyoid  bone. 

Submucous  hemorrhages  into  the  larynx  and  the  adjacent  parts  deserve 
the  interest  of  the  specialist  as  well  as  of  the  general  practitioner  the 
more,  as  they  are  liable  to  cause  sudden  death  under  symptoms  of  acute 
oedema  glottidis.  The  proper  use  of  the  laryngoscope  at  the  right  time  is 
of  the  utmost  importance,  and  will  go  far  to  save  the  patient's  life.  The 
causes  are  manifold,  and  cannot  well  be  schematized.  Pfeufer4  lost  a 
patient  who  had  acquired  severe  stomatitis  by  excessive  use  of  mercurial 
ointment,  on  account  of  parasites.  On  the  third  day  after  his  reception 
into  the  hospital,  symptoms  of  laryngeal  stenosis  set  in,  and  he  died  from 
suffocation  five  hours  afterwards.  The  post-mortem  revealed  a  submucous 
effusion  of  blood  of  one  square  inch  extension  below  the  right  ventricle. 
Ruehle5  remarks  that  similar  effusions  have  been  observed  in  scurvy,  and 
Immermann6  says  that  the  mucous  membrane  of  the  bronchi  and  larynx 
in  this  disease  almost  always  shows  extended  and  numerous  ecchymoses, 

1  Gross,  S.  D.,  A  Practical  Treatise  on  Foreign  Bodies  in  the  Air-Passages.  Phila- 
delphia, Blanchard  &  Lea,  1854,  p.  79. 

2  Gibb,  Geo.  D.,  on  Diseases  of  the  Throat  and  "Windpipe.  London,  Churchill  & 
Sons,  1864,  p.  264. 

3  Tuerk,  L.,  Klinik  der  Krankheiten  des  Kehlkopfs  und  der  Luftrohre.  Wien,  Brau- 
mueller,  1866,  p.  402. 

4  Pfeufer,  L.,  Larynxapoplexie,  Zeitschrift  fur  rationelle  Medizin,  III.  Band,  1845. 
p.  143  (not  neue  Folge  III.  Band,  as  generally  erroneously  quoted). 

5  Ruehle,  H.,  die  Kehlkopf krankheiten,  Berlin,  Hirsclnvald,  1861,  p.  172. 

6  Immermann,  H.,  in  Ziemssen's  Handbuch  der  speciellen  Pathol ogie  und  Theraxne, 
Leipzig,  Vogel,  1876,  Band  XIII.  part  2,  p.  608. 


1885.] 


Gle its maxx,  Laryngeal  Hemorrhage. 


403 


and  is  covered  with  bloody  mucus.  Poisoning  with  phosphorus  produces 
like  conditions,  according  to  Gottstein.1 

Bogros'2  relates  two  cases  of  hemorrhagic  variola  with  exitus  lethalis, 
both  of  which  had  sanguineous  infiltration  of  the  ary-epiglottic  folds.  In 
one  of  them  they  attained  the  thickness  of  two  centimetres,  and  com- 
pletely occluded  the  aditus  laryngis.  The  glosso-epiglottic  folds  pre- 
sented the  same  aspect,  and  interfered  thereby  with  the  mobility  of  the 
epiglottis.  Suicidal  attempts  also  contribute  their  share  to  this  subject. 
Probably  the  oldest  two  on  record  are  by  Bobillier.3  A  workman  cut 
himself  with  a  razor,  and  inflicted  a  horizontal  wound  about  six  centi- 
metres long  between  the  hyoid  bone  and  the  thyroid  cartilage.  After  it 
was  dressed  he  felt  well  till  the  fifth  day,  when  symptoms  of  laryngeal 
stenosis  appeared,  to  which  the  patient  succumbed.  The  post-mortem 
showed  severance  of  the  upper  and  anterior  part  of  the  thyroid  cartilage  and 
of  the  hyo-thyroid  membrane,  bloody  infiltration  of  the  right  ary-epiglottic 
fold,  and  oedema  of  the  laryngeal  aperture.  The  second  patient  was  a 
soldier  who  set  a  triangular  wound  of  an  inch  and  a  half  in  length  on  the 
right  side  of  the  throat,  which  did  not  bleed  until  after  four  hours. 
A  tampon  stopped  the  bleeding  towards  the  surface,  but  a  soft  bluish 
tumor  formed  on  the  left  lower  maxilla,  and  although  the  bandage  was 
removed  again,  the  patient  died  from  suffocation.  Dissection  showed 
that  the  wound  did  not  penetrate  into  the  larynx,  but  that  the  entire  cellu- 
lar tissue  of  the  anterior  part  of  the  throat  was  filled  with  blood,  and  the 
infiltration  of  the  mucous  membrane  of  the  arytenoid  cartilage  was  so 
great  that  the  entrance  to  the  larynx  was  obstructed.  Another  case 
belonging  to  this  category  is  described  by  Otto4  under  the  title  :  Hema- 
toma of  the  Aryepiglottic  Fold.  It  occurred  in  an  insane  man  who  cut 
himself  in  the  throat  with  a  pocket-knife,  which  wound  was  followed  by  a 
brisk  hemorrhage  on  the  outside  only.  Feeling  otherwise  perfectly  well, 
17  hours  later  severe  stridor  suddenly  set  in,  the  patient  rose  in  bed,  and 
before  the  bandage  could  be  loosened  died  within  three  minutes.  At 
the  post-mortem  no  injury  of  the  larynx  was  found,  but,  after  being 
taken  out,  two  large  black-red  tumors  appeared  lying  over  the  entrance  to 
the  larynx,  representing  the  enormously  swollen  ary-epiglottic  folds.  The 
description  and  two  good  drawings  show  that  these  tumors  commenced  on 
both  sides  of  the  base  of  the  tongue,  growing  thicker  when  forming  the 
glosso-epiglottic  folds,  and  extending  downward  to  the  posterior  sur- 
face of  the  arytenoid  cartilages.  The  right  tumor  was  three  centi- 
metres thick  and  covered  the  upper  part  of  the  cricoid  cartilage,  whilst 

1  Gottstein,  J.,  Krankheiten  des  Kehlkolpfs,  etc.,  Wien,  Toeplitz  undDeutike,  1884. 

2  Bogros,  Si.,  Bulletin  de  la  Societe  anatomique  de  Paris,  1847,  p.  141  ;  also  in 
Sestier's  Traite  de  l'angine  laryngee  cedemateuse,  Paris,  1852,  pp.  63  and  114. 

3  Bobillier.  M.,  Ptecneil  de  memoirs  de  medecine,  de  ckirurgie  et  de  pharmacie  mili- 
taire,  torn.  viii.  1820,  pp.  110, 113  ;  also  in  Sestier  1.  c.  pp.  137,  138. 

4  Otto,  A.,  Deutsches  Archiv  fur  klinische  Medizin,  vol.  xxvii.  1SS0,  p.  5S0. 


404  Jackson,  Measurement  of  Refraction  by  the  Shadow-test.  [April 


the  left  one. had  a  thickness  of  two  centimetres.  Each  one  had  an  exten- 
sion up  and  downwards  ;  the  latter  was  visible  only  after  dissecting  and 
drawing  apart  of  the  larynx.  The  left  branch  was  smaller,  and  ended  one 
centimetre  above  the  ventricle  ;  the  right  embraced  the  whole  length  of 
the  right  ventricular  band,  and  ended  in  the  ventricle,  thereby  completely 
occluding  the  cavum  laryngis,  when  the  latter  was  adjusted  again.  The 
remarkable  feature  of  the  case  was  that  each  of  the  two  blood  tumors  was 
separate,  and  had  no  communication  with  the  other.  Of  this  fact  Otto 
acknowledges  himself  unable  to  give  a  satisfactory  explanation. 

Lefferts1  had  a  girl  under  treatment  who  carried  a  hat-block  in  her 
arms  ;  in  falling  the  block  was  caught  between  the  right  side  of  the  neck 
and  the  curbstone.  During  night  the  respiration  became  labored,  and 
next  morning  the  right  aryepiglottie  fold  was  seen  filled  and  enormously 
distended  by  effused  blood,  giving  it  a  dark  bluish-red  appearance.  The 
blood  became  readily  absorbed,  and  after  a  few  days  all  signs  of  the 
previous  condition  had  disappeared. 

Sommerbrodt2  saw  darkened  suggillations  in  both  cords,  and  a  large  one 
in  the  right  ventricular  band  in  a  pregnant  woman  with  acute  laryngitis. 
He  further  gives  the  history  of  a  girl  who  had  the  sensation  of  something 
sticking  in  her  throat  two  hours  after  eating.  The  laryngoscope  showed 
a  black  round  mass  of  cherry  stone  size  in  the  middle  part  of  the  posterior 
laryngeal  wall.  It  was  soft  to  the  touch  of  the  probe,  and  when  lanced 
proved  to  be  a  submucous  effusion  of  blood  in  the  inter-arytenoid  region. 
The  same  author3  relates  as  a  curiosity  a  case  of  hemorrhage  into  an 
unusually  large  cyst  of  the  epiglottis  after  its  puncture. 

These  examples  of  submucous  hemorrhages,  to  which  more  could  be 
readily  added,  may  serve  to  illustrate  sufficiently  their  difference  in  cause, 
character,  and  symptoms  from  hemorrhages  on  the  free  surface,  and  to 
show  the  propriety  of  giving  the  latter  a  distinctive  name  when  not  arising 
from  some  extrinsic  cause. 


Article  VII. 

The  Measurement  of  Refraction  by  the  Shadow-test,  or  Retino- 
scopy.  By  Edward  Jackson,  A.M.,  M.D.,  of  Philadelphia,  Clinical 
Assistant  in  the  Eye  Department  of  the  Philadelphia  Polyclinic,  and  the  Eye 
and  Ear  Department  of  the  Pennsylvania  Hospital. 

Ten  years  ago  Cuignet,  of  Lille,  had  described  a  form  of  this  test, 
calling  it  heratoscopie ;  but  his  paper  upon  the  subject  seems  to  have  made 

1  Lefferts,  G.  W.,  New  York  Medical  Journal,  vol.  xxvi.,  August,  1877,  p.  207. 

2  Sommerbrodt,  J.,  Berliner  klinische  Wochenschrift,  No.  13,  1878. 

3  Same,  Breslauer  aerztliche  Zeitsclirift,  1881,  pp.  109-111. 


1885.]   Jackson,  Measurement  of  Refraction  by  the  Shadow  test.  405 

no  change  in  the  methods  of  practical  ophthalmologists.  In  1878,  how- 
ever, his  pupil,  Dr.  Mengin,  introduced  the  practice  of  the  method  at 
Galezowski's  clinic,  in  Paris.  Here  it  was  taken  up  by  Dr.  Parent,  who 
demonstrated  its  optical  basis,  described  a  method  of  using  it,  and  urged 
its  advantages  in  a  series  of  articles  published  in  the  Recueil  d'  Ophthal- 
mologic, 1880.  The  name  keratoscopie  was  given  on  the  supposition 
that  the  play  of  light  and  shade,  with  which  the  test  is  specially  con- 
cerned, was  solely  dependent  on  the  form  of  the  cornea.  Parent,  finding 
that  this  play  was  really  due  to  the  movement  of  an  area  of  light  on  the 
pigment  layer  of  the  retina,  called  the  method  retinoscopie.  In  this  he 
erred  in  giving  a  name  equally  applicable  to  other  ophthalmoscopic  exami- 
nations. The  name  best  descriptive  of  the  test  is  probably  fantoscopie 
retinienne,  proposed  by  Chibret. 

Priestley  Smith  has  called  it  the  shadow-test,  and  Hartridge  proposes 
umbrascopy.  Both  names  are  brief  and  distinctive  ;  but  retinoscopy  has 
been  so  far  sanctioned  by  use  that,  probably,  it  will  not  be  replaced  by 
any  other  term.  Keratoscopy  must  be  dropped.  It  is  misleading,  as  is 
well  illustrated  by  the  reference  to  Charnley's  paper,  to  be  found  in  the 
Index  Medicus,  under  the  head  of  "  Diseases  of  the  Cornea." 

In  1881,  Parent  spent  some  time  at  the  Royal  London  Ophthalmic 
Hospital,  and  introduced  the  test  there.  It  had  already  been  noticed  by 
Forbes  {Roy.  Lond.  Oph.  Hosp.  Rep.,  1880,  p.  62)  ;  but  only  after  the 
visit  of  Parent  did  English  ophthalmologists  take  it  up  with  apparent 
enthusiasm  ;  Charnley  giving  a  description  of  it,  and  the  fullest  demon- 
stration of  its  optical  basis,  in  the  Royal  London  Ophthalmic  Hospital 
Reports  (1882,  p.  344),  Morton  describing  it  in  his  work  on  Refraction, 
and  Juler  in  the  Ophthalmic  Review  (1882,  p.  327),  and  in  the  British 
Medical  Journal  (1882,  ii.  p.  670).  Since  then  a  considerable  number 
of  ophthalmic  surgeons  resident  in  London,  or  more  or  less  intimately 
connected  with  the  professional  life  of  that  metropolis,  have  written  to 
urge  the  advantages  of  the  shadow-test ;  and  it  has  taken  a  prominent 
place  in  the  text-books  emanating  from  this  medical  centre.  See  those 
by  Morton,  Hartridge,  Juler,  Swanzy,  and  the  late  editions  of  MacNamara 
and  others.  The  same  thing  might  be  said  of  Paris,  and  the  literature 
emanating  from  its  ophthalmologists  and  their  intimate  associates.  But 
elsewhere  this  method  of  measuring  refraction  has  scarcely  been  alluded 
to  ;  and  I  have  been  able  to  find  but  a  single  brief  and  inadequate  descrip- 
tion of  it  that  has  been  published  on  this  side  of  the  Atlantic.  This 
neglect  of  the  shadow-test  is  not  without  parallel.  Other  means  of  exact 
diagnosis,  now  generally  employed,  have  made  the  same  slow  progress  to 
professional  favor.  I  am  informed  that  it  was  not  until  about  1870  that 
ophthalmologists  of  this  city  began,  habitually,  to  examine  the  fundus  by 
the  direct  method.  A  description  of  the  ophthalmoscope  did  not  appear 
in  this  Journal  until  1853,  and  then  only  as  a  quotation  from  an  article 


406   Jackson,  Measurement  of  Refraction  by  the  Shadow-test.  [April 

published  in  a  foreign  journal ;  and  it  was  not  until  eight  years  later  that 
there  appeared  in  these  pages  the  recorded  results  of  an  ophthalmoscopic 
examination  made  by  an  American  surgeon.  How  strangely  these 
instances  contrast  with  the  mushroom-like  growth  of  a  literature  pertain- 
ing to  therapeutic  measures,  such  as  the  use  of  jequirity  or  cocaine  ! 

With  regard  to  the  shadow-test,  there  is  special  reason  for  its  slow 
adoption,  in  that  the  refraction  of  most  eyes  can  be  accurately  measured 
by  methods  already  in  general  use.  Then  its  advocates  have  nearly  all 
described  its  application  with  the  concave  minor  ;  a  form  of  the  test  com- 
paratively complex  in  theory  and  tedious  in  application,  and,  hence, 
offering  the  minimum  of  advantage  from  the  maximum  of  effort  spent  in 
acquirement.  The  text-books  and  journal  articles,  above  referred  to,  all 
describe  this  form  of  the  test. 

In  1882,  Dr.  Chibret  published,  in  the  Annates  oV  Oculistique  (vol. 
xxxviii.  p.  238),  an  article  on  the  "Determination  Quantitative  de  la 
Myopie  par  la  Keratoscopie  (Fantoscopie  Retinienne),  a  l'Aide  d'un  Sim- 
ple Miroir  Plan,"  which  set  forth  the  advantages  of  the  shadow-test  with 
the  plane  mirror,  in  determining  the  presence  and  degree  of  myopia  in 
the  examination  of  large  numbers  of  recruits.  In  the  Ophthalmic  Review 
for  August,  1883  (p.  228),  appeared  John  B.  Story's  article  on  "  The 
Advantages  of  the  Plane  Ophthalmoscopic  Mirror  in  Retinoscopy." 
Story  seems  to  have  commenced  to  use  the  plane  mirror  before  the  appear- 
ance of  Chibret's  paper ;  but  he  failed  to  appreciate  and  embody  in  the 
method  he  described  the  greatest  advantage  of  the  shadow-test  with  the 
plane  mirror,  namely,  the  capacity  to  determine  exactly  the  kind  and 
amount  of  ametropia  with  but  one  or  two  changes  of  the  lens  placed  before 
the  patient's  eye. 

Finally,  Priestley  Smith  has,  in  the  Ophthalmic  Review  (1884,  p.  266), 
described  "  A  Simple  Ophthalmoscope  for  the  Shadow-test,"  and  given 
some  valuable  hints  as  to  the  method  of  its  use.  Though  the  special  form 
of  the  shadow-test  developed  below  has,  I  believe,  never  before  been 
described,  suggestions  of  its  essential  features  may  be  found  in  these  three 
papers  by  Chibret,  Story,  and  Smith. 

Method  of  Examination — The  patient,  with  his  accommodation  at  rest, 
is  placed  in  the  dark  room,  with  the  source  of  light  just  above  his  head, 
and  far  enough  back  to  leave  his  face  in  shadow.  He  is  told  to  look  at 
the  observer's  forehead.  The  observer  stands  in  front  of  the  patient 
armed  with  a  plane  mirror ;  the  simplest  form  being  a  piece  of  looking- 
glass  one  inch  wide,  three  inches  long,  with  the  silvering  scraped  from 
two-thirds  its  length,  and  a  hole  three  millimetres  in  diameter  at  the 
centre  of  the  square  that  remains.  With  this  mirror  the  light  is  reflected 
upon  the  patient's  eye  and  face.  Now,  by  rotating  the  mirror  to  the  right 
about  its  vertical  axis,  the  area  of  light  upon  the  patient's  face  (facial 
area)  is  made  to  move  to  the  right ;  by  rotating  it  in  the  opposite  direc- 


1885.]   Jackson,  Measurement  of  Refraction  by  the  Shadow-test.  407 

tion,  the  facial  area  is  moved  to  the  left.  By  rotating  it  in  other  direc- 
tions about  other  axes,  the  facial  area  may  be  made  to  move  upward  or 
downward,  either  vertically  or  at  any  oblique  angle.  Now  the  light 
which  falls  on  the  pupil  passes  back  and  forms  on  the  pigment  coat  of  the 
retina  a  second  smaller  area  of  light,  the  retinal  area.  This  retinal  area, 
it  can  be  readily  demonstrated,  moves  when  the  facial  area  moves,  and 
always  "with"  it,  that  is,  in  the  same  direction.  But  the  observer,  by 
placing  his  eye  at  the  central  aperture  of  his  mirror,  can  study  in  the 
patient's  pupil  the  direction  of  the  apparent  movement  of  this  retinal  area. 
This  will  correspond  to  the  direction  of  real  movement  when  an  erect 
image  is  viewed,  but  will  be  the  opposite  of  the  direction  of  real  move- 
ment when  an  inverted  image  is  under  inspection.  Hence,  the  real 
movement  of  the.  retinal  area  being  always  with  the  facial  area  ;  when  the 
apparent  movement  of  the  retinal  area  is  with  the  facial  area,  the  fundus 
is  perceived  in  the  erect  image;  when  the  apparent  movement  of  the 
retinal  area  is  against  the  movement  of  the  facial  area,  the  fundus  is  per- 
ceived in  the  inverted  image.  So  much  for  the  optical  basis  of  the 
test.  Let  us  now  consider  its  practical  application  in  the  various  states  of 
refraction. 

Simple  Myopia  Rays  of  light  from  any  given  point  of  the  retina 

emerge  from  the  myopic  eye  convergent,  and  meet  at  the  point  in  front 
of  the  eye,  for  which  the  eye  is  optically  adjusted.  The  accommodation 
being  in  abeyance,  this  will  be  the  far  point  of  distinct  vision.  So  that 
there  is  formed  at  the  far  point  of  the  myopic  eye  an  inverted  image  of 
the  retina.  If  now  the  eye  of  the  observer  be  placed  between  the  patient's 
eye  and  its  far  point,  there  will  be  seen  an  erect  image  of  the  patient's 
retina ;  but  if  the  observer  view  the  patient's  eye  from  somewhere  beyond 
its  far  point,  he  will  see,  not  an  erect  image,  but  the  inverted  image 
formed  at  that  far  point.  In  the  first  case  the  boundary  of  light  and 
shade  which  marks  the  border  of  the  retinal  area  will  appear  to  move  with 
the  facial  area ;  in  the  second  case,  against  it.  In  practice  the  surgeon 
begins  the  examination  somewhat  more  distant  from  the  patient  than 
the  far  point  of  the  eye  under  examination.  Then  he  slowly  approaches 
the  patient,  all  the  while  watching  the  apparent  movement  of  the  re- 
tinal area  produced  by  slightly  rotating  the  mirror  from  side  to  side 
about  its  axis.  As  long  as  this  apparent  movement  is  opposed  to  that  of 
the  facial  area,  the  surgeon  knows  he  is  watching  the  inverted  image  at 
the  patient's  far  point.  Presently,  however,  the  direction  of  the  move- 
ment of  the  retinal  area  cannot  be  distinguished,  the  far  point  has  now 
been  reached  ;  and  coming  still  closer  the  apparent  movement  again  be- 
comes distinct,  but  is  seen  to  correspond  in  direction  with  the  real  move- 
ment, the  far  point  has  now  been  passed,  and  the  patient's  retina  is  being 
viewed  in  the  erect  image.  By  noting  the  point  at  which  this  reversal 
occurs,  the  surgeon  notes  the  far  point  of  the  eye  under  observation ;  by 


408   Jackson,  Measurement  of  Refraction  by  the  Shadow-test.  [April 

measuring  the  distance  from  this  point  of  reversal  to  the  eye,  he  measures 
the  distance  from  the  patient  to  his  far  point  of  distinct  vision  ;  and  the 
reciprocal  of  this  distance,  of  course,  expresses  the  degree  of  his  myopia. 
Thus,  supposing  the  point  of  reversal  to  be  one-fourth  of  a  metre  in  front 
of  the  eye,  one  divided  by  one-fourth  equals  four,  the  number  of  dioptres 
of  myopia  present. 

Theoretically,  the  method  as  now  described  is  complete,  but  for  con- 
venience and  accuracy  in  its  application,  one  or  two  other  points  must  be 
attended  to.  When  the  observer's  eye  has  come  quite  close  to  the  pa- 
tient's, say  to  within  one-eighth  of  a  metre,  and  the  inverted  image  is 
still  seen  between  them,  it  is  best  to  place  a  concave  lens  ( — 8.  D)  before 
the  patient's  eye,  and  then  to  estimate  the  amount  of  myopia  remaining 
uncorrected  ;  and  by  adding  it  to  the  amount  which  the  lens  used  has  cor- 
rected, determining  the  total  myopia  present.  When  the  observer  has 
approached  so  near  the  inverted  image  that  it  lies  closer  to  his  eye  than 
his  near  point  of  distinct  vision,  he  can  no  longer  see  that  image  dis- 
tinctly. Still  he  can  distinguish  in  which  direction  the  retinal  area 
appears  to  move,  until  he  approaches  somewhat  nearer  to  the  image, 
when  the  circles  of  diffusion  upon  his  own  retina  become  so  large  that  the 
retinal  area  of  light,  seen  in  the  patient's  pupil,  seems  very  diffuse  and 
faint,  and  the  direction  of  its  apparent  movement  uncertain.  Because  of 
this,  there  is  great  practical  difficulty  in  determining  exactly  where  the 
point  of  reversal  is  situated.  Now  it  is  evident  that  if  the  point  of  reversal 
is  within  a  few  inches  of  the  eye,  an  error  of  two  or  three  inches  as  to  its 
position  entails  an  error  of  some  dioptres  in  the  amount  of  myopia  pre- 
sent. Therefore,  when  by  the  method  above  described  the  degree  of 
myopia  has  been  approximately  ascertained,  place  before  the  patient's  eye 
a  concave  lens  strong  enough  to  remove  the  point  of  reversal  a  metre  or 
more  from  the  eye.  At  such  a  distance,  an  error  of  two  or  three  inches 
as  to  the  position  of  the  point  of  reversal  is  of  no  consequence ;  and  an 
accurate  determination  of  the  remaining,  and  hence  of  the  total  myopia, 
can  readily  be  made.  Having  determined  the  amount  of  myopia  present, 
the  surgeon  will  of  course  be  guided  by  the  rules  he  would  follow  had  the 
myopia  been  measured  by  any  other  method. 

Hypermetropics  On  viewing  the  fundus  reflex  it  is  found  that  at  all 

distances  the  erect  image  is  seen,  and  the  retinal  area  appears  to  move 
with  the  facial  area.  Place  before  the  patient's  eye  a  convex  lens  strong 
enough  to  over-correct  the  hypermetropia.  Then,  by  the  method  given 
above,  determine  the  degree  of  myopia  so  produced.  Deduct  this  amount 
of  myopia  from  the  strength  of  the  convex  lens  used  ;  and  the  remainder 
will  express  the  degree  of  hypermetropia  present.  Suppose,  for  example, 
the  hypermetropia  amounts  to  four  dioptres.  Placing  a  five  dioptre  con- 
vex lens  before  the  eye  it  is  found  that  one  dioptre  of  myopia  is  produced, 
the  point  of  reversal  being  at  one  metre.    Then  five,  minus  one,  equals 


1885.1    Jacks  ox,  Measurement  of  Refraction  by  the  Shadow-test.  409 

four,  which  expresses  in  dioptres  the  amount  of  hypermetropia  present. 
Should  it  be  found  that  the  -[-  5  .  D.  lens  leaves  the  eye  hypermetropic, 
so  that  the  erect  image  is  seen  at  all  distances,  replace  it  by  a  -j-  10  .  D., 
and  proceed  as  before.  As  in  myopia,  however,  the  final  accurate  deter- 
mination should  be  made  at  a  distance  of  not  less  than  one  metre.  It 
may  be  noticed  that  low  degrees  of  myopia  may  be  measured  without  the 
use  of  any  lens,  but  that  to  determine  the  degree  of  hypermetropia  pre- 
sent, a  convex  lens  is  always  necessary. 

Emmetropia  is  determined  by  the  method  for  measuring  hypermetropia. 
The  convex  lens  being  placed  before  the  eye,  the  resulting  myopia  is 
found  to  equal  exactly  the  strength  of  the  lens  in  use. 

Regular  Astigmatism. — In  applying  the  test  to  the  measurement  of 
regular  astigmatism,  instead  of  rotating  the  mirror  about  any  axis,  ver- 
tical, horizontal,  or  oblique,  as  may  be  done  when  the  curvature  of  the 
cornea  is  the  same  in  all  directions,  it  is  rotated  about  axes  perpendicular 
to  the  directions  of  the  principal  meridians  of  curvature,  and  the  point  of 
reversal  thus  found  for  each  principal  meridian.    To  determine  the  direc- 
tion of  these  principal  meridians,  the  eve,  if  not  previously  so,  should  be 
rendered  myopic  in  all  meridians,  and  then  viewed  from  different  dis- 
tances.   It  will  then  be  found  that  at  certain  points  the  fundus  reflex 
takes  the  shape  of  a  more  or  less  distinct  band  of  light  stretching  across 
the  pupil,  while  on  one  or  both  sides  of  it  may  be  seen  a  shaded  area, 
"  the  somewhat  linear  shadow"  of  Bowman.    This  band  of  light  is  very 
readily  moved  in  a  direction  perpendicular  to  its  length,  but  in  the  direc- 
tion of  its  length  cannot  be  made  to  move  at  all.    The  point  where  this 
appearance  is  presented  is  the  point  of  reversal  for  that  principal  meridian 
of  the  cornea,  whose  direction  coincides  with  the  length  of  the  band.  The 
other  principal  meridian  is,  of  course,  at  right  angles  to  this  ;  and  the 
observer  by  placing  his  eye  at  its  point  of  reversal  will  be  in  position  to 
see  a  similar  band  extending  in  a  direction  perpendicular  to  that  of  the 
band  first  observed.    This  use  of  the  shadow-test  may  be  made  clearer  by 
the  consideration  of  what  occurs  in  a  particular  case.    Suppose  the  pa- 
tient's cornea  to  have  such  a  curvature  as  to  cause  in  the  horizontal 
meridian  (axis  vertical)  a  hypermetropia  of  four  dioptres,  and  in  the 
vertical  meridian  (axis  horizontal)  a  myopia  of  one  dioptre.    Place  before 
the  eye  a  -|-  5  .  D.  spherical  lens.    On  approaching  it  from  a  distance,  it 
is  found  that  the  retinal  area  moves  against  the  facial  area  in  all  direc- 
tions.   But  as  the  distance  of  one  metre  is  approached,  it  is  noticed  that 
the  retinal  area  takes  the  form  of  a  horizontal  band,  readily  movable 
upward  or  downward,  but  difficult  to  move  to  the  right  or  left ;  and  when 
the  point  of  one  metre  is  reached,  all  movement  to  the  right  or  left  ceases, 
and  the  band  is  most  distinct.    Going  still  closer,  the  point  of  reversal 
for  the  horizontal  meridian  being  passed,  movement  to  the  right  or  left 
reappears,  but  it  is  now  with  the  facial  area.    The  movement  upward  or 


410   Jackson,  Measurement  of  Kefraction  by  the  Shadow-test.  [April 

downward  is  still  against  that  of  the  facial  area.  As  the  patient  is  still 
approached,  the  appearance  of  a  horizontal  band  fades  out,  and  presently 
is  replaced  by  that  of  a  vertical  band.  The  vertical  band  moves  readily 
to  the  right  or  left,  but  less  distinctly  upward  or  downward,  and  at  one- 
sixth  of  a  metre  all  vertical  motion  is  lost.  This  is  the  point  of  reversal 
for  the  vertical  meridian.  On  approaching  still  closer,  vertical  movement 
reappears,  but  like  the  horizontal  movement  it  is  now  with  the  facial  area, 
not  against  it.  Thus  it  is  found  that  for  the  horizontal  meridian  the  point 
of  reversal  is  one  metre  distant  from  the  eye,  and  that  for  the  vertical 
meridian  the  point  of  reversal  is  one-sixth  metre  distant.  That  is,  the 
use  of  the  convex  lens  has  made  the  eye  myopic  in  the  one  meridian  one 
dioptre,  in  the  other  meridian  six  dioptres ;  and  by  taking  into  account 
the  effect  of  the  spherical  lens  used,  the  mixed  astigmatism  is  seen  to  be 
what  we  supposed  it.  But  for  accurate  work,  as  in  simple  myopia  and 
hypermetropia,  the  degree  of  ametropia  for  each  meridian  should  be  finally 
determined  with  such  a  lens  before  the  eye  as  would  place  the  point  of 
reversal,  for  that  meridian,  one  metre  or  more  distant. 

The  apparent  form  of  the  fundus -reflex,  its  brightness  and  rapidity  of 
movement  are  matters  of  very  little  importance  in  connection  with  the 
shadow-test,  as  I  have  endeavored  to  describe  it ;  except  in  the  case  of 
astigmatism.  Of  regular  astigmatism  I  have  spoken.  Of  irregular  astig- 
matism, it  may  be  said  that  it  gives  to  the  fundus  reflex  forms  infinitely 
numerous.  Two  only  need  be  mentioned  here,  the  central  bright  point 
and  shaded  circle  by  central  illumination,  changing  to  a  light  and  a 
shaded  area,  separated  by  a  boundary  angular  at  the  centre  of  the  cornea, 
when  the  mirror  is  turned,  which  has  long  been  known  to  indicate  conical 
cornea  ;  and  a  bright  circle  at  the  margin  of  the  pupil,  with  a  fainter  cen- 
tral area,  which  indicates  curvature  of  the  crystalline  lens,  greater  towards 
the  margin  than  near  the  centre  of  the  pupil.  Generally  this  condition 
exists,  if  the  pupil  be  fully  dilated,  and  the  effect  is  puzzling  to  one  un- 
practised in  the  shadow-test,  because  the  ring  or  crescent  at  the  edge  of 
the  pupil  reverses  closer  to  the  eye  than  does  the  image  at  the  centre  of  the 
pupil ;  and  the  latter  reversal,  though  less  striking,  is  the  one  of  practical 
importance.  The  danger  of  the  error  being  recognized,  however,  it  will, 
after  a  little  practice,  be  readily  avoided.  Although  the  presence  of 
irregular  astigmatism  thus  makes  the  shadow-test  somewhat  more  difficult 
of  application,  the  test  in  certain  cases,  as  in  the  "  facetted"  cornea,  cer- 
tainly affords  the  best  means  of  measuring  the  general  state  of  refraction. 
It  is  a  point  of  practical  importance  that  the  appearance  of  the  fundus- 
reflex  also  depends  on  the  shape,  size,  and  practical  distance  of  the  source 
of  light ;  the  practical  distance  of  the  source  of  light  being  the  distance 
from  the  light  to  the  mirror,  plus  the  distance  from  the  mirror  to  the 
patient's  eye.  A  large  irregular  flame,  close  to  the  patient's  eye,  will  not 
give  the  band-like  appearance  characteristic  of  regular  astigmatism ; 


1885.1   Jacks  ox,  Measurement  of  Eefraetion  by  the  Shadow-test.  411 

this  appearance  being  presented  only  in  so  far  as  the  source  of  light  ap- 
proximates to  the  condition  of  a  mathematical  point.  On  the  other  hand, 
the  source  of  light  must  not  be  so  small  that  the  fundus-reflex  will  en- 
tirelv  disappear  when  the  light  is  reflected  to  the  patient's  eye  from  the 
region  of  the  central  aperture  in  the  mirror. 

The  advantages  of  the  shadow-test,  as  above  described,  are,  that  it  is 
most  widely  applicable,  has  the  certainty  of  an  objective  method,  the 
accuracy  of  trials  with  test-lenses,  and  the  rapidity  of  the  optometer.  It 
is  applicable  in  the  cases  of  young  children,  the  amblyopic  and  malin- 
gerers, in  which  subjective  tests  cannot  be  used  :  and  in  cases  where  rest- 
lessness, nvstagmus,  hazy  media,  or  the  loss  of  the  other  eye.  render 
accurate  examination  in  the  erect  image  by  a  refraction  ophthalmoscope 
difficult  or  impossible.  In  certainty,  when  the  patient  retains  the  power 
of  accommodation,  it  seems  to  me  inferior  to  the  "  direct  method"'  as  a 
means  of  discovering  and  measuring  latent  hypermetropia.  But  it  is 
superior  to  the  direct  method  in  the  detection  and  estimation  of  astig- 
matism. 

Assuming  that  the  amount  of  regular  astigmatism  does  not  vary,  by 
reason  of  unequal  contraction  of  the  ciliary  muscle,  quite  low  degrees  of 
it  (less  than  a  half  dioptre)  can  be  recognized,  measured,  and  the  axis 
fixed,  in  the  face  of  varying  accommodation.  Again,  the  shadow-test  is 
free  from  any  possibility  of  error  due  to  the  observer's  unconscious  accom- 
modation ;  and  this  seems  to  me  no  small  mattpr.  at  least  for  young 
observers.  I  know  there  are  times  when,  after  taxing  my  own  eyes  with 
close  work,  a  certain  error  of  unconscious  accommodation  vitiates  my 
work  with  the  refraction  ophthalmoscope.  The  shadow-test  avoids  this 
entirely.  Charnley  has  stated  (he.  cit..  p.  357)  that  "  the  observer,  if  not 
emmetropic,  must  correct  his  ametropia,"  and  the  error  is  perpetuated  in 
the  American  description  of  the  shadow-test,  as  practised  in  English 
hospitals.  (A.  R.  Baker,  Retinoscopy,  Am.  Joum.  of  Ophthalmology, 
vol.  i.  p.  116.) 

The  observer's  ametropia  only  interferes  with  the  use  of  the  shadow- 
test  when  it  prevents  him  from  seeing,  with  sufficient  clearness,  objects  a 
few  feet  distant.  In  accuracy,  the  test  in  my  experience  very  nearly 
equals  the  subjective  test  with  trial  lenses  for  patients  who  have  good 
vision,  good  intelligence,  and  honesty  ;  for  patients  lacking  in  any  of  these 
requisites  for  subjective  testing,  it  is  markedly  more  accurate  than  any 
other  method.  In  all  cases  where  the  state  of  refraction  is  to  be  mea- 
sured accurately,  it  effects  a  saving  of  time ;  in  the  stupid  or  sluggish  this 
saving  is  very  great. 

The  shadow-test  may  be  looked  upon  as  the  union  and  evolution  of  two 
modes  of  examination  almost  as  old  as  the  ophthalmoscope  itself,  namely, 
the  twirling  of  the  mirror  to  detect  conical  cornea,  and  the  examination 
of  the  myopic  eye  by  the  indirect  method,  without  the  intervention  of  an 


412         Kemper,  Rupture  of  Membranes  during  Gestation.  [April 

object  lens.  Those  who  desire  to  study  more  minutely  the  history  of  that 
evolution,  and  to  assign  due  credit  to  those  who  have  aided  in  the  process, 
will  find  the  appended  references  a  valuable  addition  to  those  already 
given  in  the  text. 

Wm.  Hoioman,  Paper  on  Conical  Cornea,  Roy.  Lond.  Oph.  Hosp.  Reports,  vol.  ii.  p. 
157.  F.  C.  Bonders,  Accommodation  and  Refraction,  London,  1864,  pages  106,  490, 
and  551.  John  Couper,  The  Ophthalmoscope  as  an  Optometer  in  Astigmatism  ;  Report 
of  the  Fourth  International  Ophthalmological  Congress,  London,  1872,  page  109.  E. 
G.  Loring,  Determination  of  the  Refraction  of  the  Eye  with  the  Ophthalmoscope,  New 
York,  1876,  pages  47-51. 


Article  VIII. 

A  Study  of  the  Subject  of  Spontaneous  Rupture  of  the  Membranes 
at  Full  Term  of  Gestation  preceding  the  beginning  of  Labor. 
By  G.  W.  H.  Kemper,  M.D.,  of  Muncie,  Indiana. 

My  attention  was  first  called  to  this  subject  eleven  years  ago,  upon 
reading  this  statement :  "  Having  described  the  formation  of  the  bag  of 
waters,  Dr.  Gartipny  proves,  by  the  notes  of  two  thousand  deliveries, 
that  its  spontaneous  rupture  is  of  frequent  occurrence.  The  premature 
flow  of  the  waters  hastens  the  labor,  and  exercises  no  injurious  influence 
on  the  mother  or  child.  Its  occurrence  is  therefore  favorable  when  preg- 
nancy has  arrived  at  full  term."1 

This  declaration  was  at  such  variance  with  my  own  opinion,  formed 
upon  the  teaching  of  standard  works  on  obstetrics,  that  I  determined  to 
investigate  the  subject.  I  accordingly  turned  to  my  obstetrical  case-book 
for  my  own  experience.  My  investigations  at  that  time  were  given  to  the 
public  in  a  paper  entitled  :  "  Is  Labor  protracted  by  early  Spontaneous 
Rupture  of  the  Membranes  ?"2  In  a  record  of  two  hundred  cases,  I  found 
the  membranes  had  ruptured  before  the  beginning  of  labor  in  ten  cases, 
showing  an  average  of  one  in  twenty  cases.  I  further  ascertained  that  in 
every  case  the  child  was  born  alive,  the  mother  did  well,  and  the  average 
duration  of  the  labors  was  eight  hours  and  six  minutes. 

A  more  extended  experience  of  ten  years  has  afforded  me  facilities  for 
an  enlarged  study  of  the  subject. 

I  offer  for  consideration  the  following  table  of  50  cases  of  spontaneous 
rupture  of  the  membranes,  occurring  in  my  first  700  obstetrical  cases.  I 
may  state  that  all  the  cases  were  carefully  recorded  in  my  case-book,  and 
I  will  vouch  for  their  accuracy. 

In  every  case  the  rupture  of  the  membranes  preceded  labor-pains,  so 
that  the  length  of  time  from  that  event  to  the  beginning  of  pains,  and  ces- 

1  Obstet.  Jour,  of  Great  Britain  and  Ireland,  Dec.  1873,  p.  629. 

2  American  Practitioner,  June,  1874,  p.  334. 


1885.]     Kemper,  Rupture  of  Membranes  during  Gestation.  -413 


sation  of  labor  was  definitely  determined.  I  have  indicated  the  expulsion 
of  the  child,  and  not  the  placenta,  as  the  time  of  reckoning.  The  dura- 
tion of  the  third  stage  of  labor  w  ould  average  about  ten  minutes. 

As  a  question  of  diagnosis,  I  may  say  that  while  I  have  met  with  cases 
of  hydrorrhcea  gravidarum,  of  authors,  they  have  not  been  included  in  the 
following:  table  : — 


From  rapture 
of  membrane 
to  beginning 
of  pains. 

Duration 

-■ 

No. 

— 

No.  of 
labor. 

of  labor 

from 
beginning 
of  pains. 

Kemarks. 

-i 
i 

oo 

YI  para 

Q    V|  ATI  T«fl 

7  hours 

o 
•S 

id 

T 
1 

•±  nuura 

CI 

X  cLLLtllt;.       V  cl  lei..  lllc^lLlLLLalt;. 

o 
O 

TTT 
1 J  1 

-A.t  once 

93/ 

cc 

^lale.  Vertex. 

■t 

all 

T 
1 

ie 

cc 

Female.    Vgrtex.  fwtjll. 

K 
O 

91 

T 
1 

SI/ 

cc 

^lale.  \  erxex.  stillborn.  ^lotner  did 

2 

-tl 

TV 
1A. 

££ 

9f| 

cc 

Female.    \  ertex.    Always  tedious. 

0»2 

-o 

v 

V 

cc 

5 

II 

!Male.    Vertex.    Rup.  while  asleep. 

17 

T 
1 

£{ 

ri 

ec 

Female.  Vertex. 

g 

OU 

Y' 

2  davs 

ft 

o 

cc 

£  cilltllc;. 

1U 

OO 

VTT 

V  JLL 

ilOUIo 

9 

cc 

^lale.   "V  ertex.    Ruo.  while  asleep. 

1 1 

oo 

VTTT 

V  XXX 

11  Y\  n  n  T~c 

1  fii/ 

1U% 

cc 

Fiinioltl         Vo"rtPY         Q    10    ^\7*  11  mp 

r  trilld.lt;.      v  trl  LtrjL.      Uj         IV  11  ttlLlltr 

1  o 
1- 

oo 

VT 
»  X 

u 

At  once 

o 

cc 

Male.    Vertex.  ^woman. 

1  "5 
lo 

OJ_ 

TT 

ti 

3  days 

cc 

Female.  " 

-|  I 

li 

91 

T 
1 

ei 

71/ 

cc 

x  trUlllie. 

1  1 

1Q 

J.  ,7 

T 

A 

tt 

• 

cc 

BUUGi 

ID 

OJ. 

TT 
1  1 

It 

o  nours 

Qi/ 

cc 

\r.-iio  cc 
Aiaie. 

1  - 

so 

tt 

At  once 

a 
o 

cc 

Female.  tk 

1  -> 

Oil 

TTT 
All 

tt 

^1/ 

cc 

!Male.    A  ertex.    i>ame  as  ^o.  lb. 

1  0 

99 

TT 
11 

It 

A.t  once 

^1/ 

cc 

\Tale.  Vertex. 

■7  1 
0-± 

TTT 
111 

It 

cc 

Female.  " 

oi 

TT 
11 

a 

3  days 

^ii/ 
o 

cc 

Female.     *'  rfootlinsr. 

09 


09 
<-.; 

TT 
11 

tt 

At  once 

cc 

Female  and  male  (twins).  "V  er.  and 

49 

99 

T 
1 

tt 

11 

cc 

^lale.    Vertex.    (A  rigid  os.) 

91 
_t 

•r>Q 

V 

a 

O  ,\  trtrb.£? 

1  A 
111 

cc 

^lale.    "\  ertex.    Rup.  after  a  fall. 

9=i 

in 

a 

9  }i  n  n  rc 

3 

cc 

^lale.  Vertex. 

Oft 
-JO 

oo 

i 

A.t  once 

Female.  " 

.t~ 

Ofi 

in 

it 

16 

cc 

ATolp  'C 

.uaie. 

OU 

ii 

a 

ce 

oy2 

cc 

\r,iQ  cc 

-UaLe. 

9Q 

9.1 
-4: 

n 

a 

^11/  hrmrc 
o-r-^  uours 

3 

cc 

Female.  {{ 

91 

n 

a 

At  once 

10% 

cc 

Male. 

ol 

AO 

n 

it 

cc 

.Male. 

Q9 

i 

it 

At  once 

8K 

cc 

Female.    Breech.  Forceps. 

33 

42 

VIII 

it 

3  hours 

cc 

Female.  Vertex. 

34 

36 

YII 

tt 

"  Soon  after'' 

cc 

Male.  " 

35 

44 

XII 

it 

Shortly  after 

17 

cc 

Male.    Breech.  Stillborn. 

36 

25 

in 

tt 

T  hours 

4M 

cc 

Female.  Vertex. 

3T 

19 

i 

it 

\y2  hours 

4i 

cc 

Female.  " 

38 

26 

n 

tt 

2  hours 

cc 

Female.  " 

39 

26 

n 

tt 

6  hours 

9K 

cc 

Female.  " 

40 

24 

n 

tt 

47  hours 

6 

cc 

Female.  " 

±1 

24 

n 

tt 

At  once 

2 

cc 

Male.    Vertex.  Rup.  While  asleep. 

4-2 

19 

i 

tt 

cc 

6 

cc 

Female.  Vertex. 

43 

24 

i 

ec 

4  days 

cc 

Male.  " 

±4 

24 

i 

CI 

5  hours 

9 

cc 

Female.  " 

45 

22 

i 

cc 

•  At  once 

21 

cc 

Female.  " 

46 

26 

n 

tt 

Female.  " 

47 

21 

i 

a 

16  hours 

Male.  <; 

48 

26 

IT 

tt 

1  hour 

Female.  " 

49 

30 

I 

a 

1  hour 

cc 

Female.  Footling,  Funis.  Stillborn. 

50 

38 

VII 

12  hours 

6 

cc 

Female.  Vertex. 

407  hours 

Average  S  h.  8  m.  24  sec. 

Xo.  CLXXYIII.— April,  1885.  27 


414         Kemper,  Rupture  of  Membranes  during  Gestation.  [April 


An  analysis  of  the  preceding  table  shows  that  spontaneous  rupture  of 
the  membranes  is  not  an  infrequent  event,  as  it  occurred  50  times  in  700 
cases,  or  one  time  in  every  14  labors.1 

In  23  instances  labor  set  in  "  at  once"  when  the  membranes  ruptured. 
In  11  other  cases  pains  had  supervened  at  the  expiration  of  four  hours. 
In  only  8  cases  were  pains  delayed  beyond  twenty-four  hours.  The 
longest  delay  was  three  weeks. 

Of  the  50  cases,  16  were  primipara?,  and  34  multipara?.  The  50  women 
were  in  labor,  aggregating  407  hours,  making  an  average  of  8  hours,  8 
minutes  and  24  seconds.2 

The  16  primipara?  were  in  labor  aggregating  161|  hours,  averaging  10 
hours  and  6^  minutes  each.  The  shortest  time  of  labor  for  a  primipara 
(No.  37)  was  4-^  hours  ;  the  longest  (No.  45)  21  hours. 

The  34  multipara?  were  in  labor  aggregating  245^  hours,  averaging  7 
hours  and  12  j  minutes  each.  The  shortest  time  of  labor  for  a  multipara 
(No.  41)  was  2  hours  ;  the  longest  (No.  6)  was  20  hours. 

A  comparison  of  the  cases  where  labor  began  early  after  rupture  of  the 
membranes,  with  those  where  it  was  delayed,  will  be  of  some  interest. 
Of  the  23  cases  in  which  pains  began  "  at  once,"  10  were  primipara?  and 
13  multipara?.  These  23  women  were  in  labor  200  hours  and  45  minutes, 
so  that  the  duration  of  labor  averaged  8  hours  and  43-J-  minutes.  Of  the 
remaining  number  27,  6  were  primipara?  and  21  multipara?.  These  27 
women  were  in  labor  206  hours  and  15  minutes,  average  duration  of  labor 
7  hours  and  38^  minutes.  This  comparison  shows  that  in  cases  where 
labor-pains  are  delayed  for  a  time,  the  duration  of  labor  is  1  hour  and  5 
minutes  shorter  than  in  cases  where  pains  supervene  "  at  once."  The  latter 
class,  however,  is  favored  by  the  greater  proportion  of  multipara?.  The 
proportion  of  primiparae  in  the  former  class  would  indicate  that  labor  is 
more  likely  to  supervene  "  at  once"  after  the  membranes  are  ruptured, 
with  primipara?  than  multipara?. 

The  ages  ranged  from  15  to  44  years — classified  as  follows:  15  to  19 
years  =  5  ;  20  to  29  years  =  29  ;  30  to  39  years  =  11  ;  40  to  44  years 
—  4  ;  and  unknown  1. 

Of  the  50  labors,  49  were  single,  and  1  a  twin  birth,  so  that  51  chil- 
dren were  born,  according  to  sex,  23  males  and  28  females.  One  child 
was  illegitimate. 

The  presentations  were  :  vertex  47,  breech  2,  and  footling  2.  Forceps 
was  used  in  one  case  (No.  32)  to  deliver  the  after-coming  head. 

1  Dr.  J.  C.  Bliss  in  820  cases  of  delivery  found  the  membranes  broke  "  before  or  at 
the  accession  of  labor"  79  times,  or  about  one  time  in  10  labors. — Am.  Jouk.  of  Med. 
Sciences,  July,  1847,  p.  272. 

2  In  Dr.  Bliss's  820  cases  (op.  cit.)  the  average  duration  of  labor  was  10%  hours. 
He  remarks  :  "  This  shows  that  this  occurrence  did  not  very  materially  retard  the  pro- 
gress of  parturition." 


1885.]     Kemper,  Rupture  of  Membranes  during  Gestation. 


415 


The  result  to  the  mother  was  favorable  in  every  case. 

The  mortality  to  the  children  was  3,  or  1  death  in  17  births  ;  2  of 
these  were  males  and  1  a  female.  The  3  cases  of  stillborn  children  were 
rather  unusual  ones,  and  such  that  a  fatal  result  was  liable  to  occur  under 
more  favorable  circumstances.  The  first  (No.  5)  occurred  with  a  primi- 
para,  of  short  stature.  The  presentation  was  a  vertex,  and  the  child,  a 
male,  weighed  ten  pounds.  The  head  was  markedly  elongated,  indicating 
a  narrow  parturient  canal.  The  case  occurred  early  in  my  practice,  before 
I  had  sufficient  courage  to  resort  to  the  forceps,  a  procedure  that  might 
have  led  to  a  better  result.  Had  the  bag  of  waters  been  present  to  a  late 
period  of  the  labor,  the  result  might  have  been  different;  if  so,  however,  I 
believe  it  is  the  only  case  of  the  three  in  which  the  fatal  result  could  be  attri- 
buted to  the  early  rupture  of  the  membranes.  Three  subsequent  labors  of 
this  woman  have  been  prolonged  and  hard.  The  second  (No.  35)  occurred 
with  a  woman  aged  44  years,  and  in  her  12th  labor.  The  child,  a  male, 
presented  by  the  breech.  The  surroundings  of  the  family  for  some  time 
previous  had  been  such  as  to  debilitate  the  patient.  The  third  (No.  49) 
was  a  primipara,  aged  30  years.  The  child,  a  female,  presented  by  both 
feet,  and  the  funis  was  prolapsed;  My  record  reads  :  "  The  head  was  not 
delayed.  I  think  the  death  was  due  to  the  continued  pressure  by  the 
body  on  the  cord." 

The  occurrence  of  the  early  rupture  of  the  membranes  would  appear  to 
be  common  to  certain  women.  Cases  9,  10,  and  11  occurred  with  the 
same  woman  in  successive  pregnancies;  also  13  and  18  are  successive 
pregnancies  of  another  woman.  Bard  mentions  this  liability  of  certain 
women.  I  have  noticed  the  occurrence  of  this  accident  in  patients 
near  the  same  date,  insomuch  that  I  have  been  led  to  suspect  that  atmo- 
spheric changes  might  be  a  factor.1  More  than  one-half  of  my  cases 
occurred  in  the  four  months  of  November,  December,  January,  and  Feb- 
ruary, a  fact  pointing  to  the  possibility  of  cold  weather  being  an  exciting 
cause. 

As  a  summary  of  the  views  and  facts  stated  in  the  foregoing  paper,  the 
following  deductions  may  be  drawn  : — 

1.  The  spontaneous  rupture  of  the  membranes  at  full  term  of  gestation, 
and  preceding  the  beginning  of  labor-pains,  is  an  event  of  common  occur- 
rence, averaging  about  once  in  every  fourteen  labors. 

2.  When  the  membranes  are  broken,  as  a  rule,  labor  supervenes  at 
once,  or  within  the  next  four  hours,  but  may  be  delayed  several  hours, 
days,  or  even  weeks. 

3.  When  such  an  accident  occurs,  the  duration  of  the  labor  is  not  neces- 
sarily prolonged,  nor  rendered  more  painful. 

1  On  November  16, 1884,  while  this  paper  was  in  preparation,  I  attended  three  women 
in  labor,  and  the  rupture  of  the  membranes  preceded  labor  in  each  case. 


416 


Councilman,  Abbott,  Malarial  Fever. 


[April 


4.  The  mortality  of  the  mothers  is  not  augmented,  and  the  ratio  of 
stillborn  children,  if  at  all,  is  so  slightly  increased  as  to  amount  to  a  mini- 
mum. 

5.  The  causes  are  not  well  defined.  The  repetition  of  the  accident  in 
certain  women  shows  that  with  some  a  tendency  is  inherent.  A  possi- 
bility of  atmospheric  influences,  especially  a  low  temperature,  as  an 
exciting  cause  is  admissible.  Smellie  considered  obesity  a  cause.  My 
observations  have  not  confirmed  his  statement.  Cazeaux  considered  that 
such  cases  were  coincident  with  a  presentation  of  the  vertex  that  is  deeply 
engaged  in  the  excavation. 

6.  It  is  probable  that  the  duration  of  labor  is  shorter  in  cases  where  the 
appearance  of  pains  is  delayed  for  some  time  after  the  membranes  are 
ruptured. 

7.  The  proper  plan  of  treatment  as  given  by  Smellie,  McClintock, 
Bard,  Denman,  and  Dewees,  and  corroborated  by  my  own  experience,  is 
rest,  if  necessary  in  a  recumbent  posture,  and  patience.  All  efforts  to 
excite  labor-pains  are  hurtful,  meddlesome,  and  mischievous.  Wait  for 
pains,  and  treat  the  case  on  general  principles  I 

8.  Finally,  that  the  fear  of  delay  and  danger  in  this  class  of  cases, — 
the  classical  "  dry  labor," — promulgated  by  our  early  obstetrical  fathers, 
and  endorsed  by  successive  authors  generally,  is  based  on  the  merest  spark 
of  truth,  and  is  one  of  those  medical  traditions  that  experience  shows  to 
be  over-estimated  and  to  a  large  degree  apocryphal ! 


Article  IX. 

A  Contribution  to  the  Pathology  of  Malarial  Fever.  By  W.  T. 
Councilman,  M.D.,  Associate  in  Pathology  Johns  Hopkins  University,  and 
A.  C.  Abbott,  M.D.,  Baltimore,  Md. 

In  the  summer  and  autumn  of  1884,  an  unusually  good  opportunity  was 
given  to  the  writers  for  the  study  of  the  pathological  lesions  produced  by 
malarial  fever.  Bay  View  Asylum,  the  almshouse  of  the  city  of  Baltimore, 
receives  a  large  number  of  malarial  cases  from  Harford  County,  and  other 
of  the  more  malarious  counties  of  the  State.  Most  of  these  cases  received 
in  the  time  named  were  of  the  ordinary  type,  recovered  soon  under  the 
use  of  antiperiodics,  and  left  the  house.  There  were,  however,  several 
cases,  nine  in  all,  that  died  either  from  the  disease  itself,  or  from  some  other 
affection  that  intervened  in  the  course  of  the  disease.  Post-mortems  were 
made  on  these  cases  a  very  short  while  (four  or  five  hours)  after  death, 
and  most  of  the  organs  subjected  to  a  critical  and  prolonged  microscopic 
examination.    Two  of  these  cases  died  from  a  form  of  malarial  poisoning, 


1885.] 


Councilman,  Abbott,  Malarial  Fever. 


417 


which,  though  not  uncommon  in  the  South,  and  especially  in  Algeria,  is 
not  met  with  very  often  in  our  latitude. 

These  two  cases  were  particularly  interesting  from  certain  changes 
found  in  the  contents  of  the  bloodvessels  in  the  brain  and  other  organs. 
These  changes  will  be  described  at  length,  because  they  seem  to  shed  some 
light  on  various  observations  which  have  been  made  by  French  authors  in 
Algeria  and  elsewhere. 

Case  I. — An  unknown  man  was  sent  to  the  almshouse  from  a  low 
boarding-house  on  Market  Space.  He  was  received  September  12th,  at 
5  o'clock  in  the  afternoon,  and  was  then  in  a  profoundly  comatose  condi- 
tion ;  temperature  in  axilla  101.4°  Fahr.  No  history  could  be  obtained 
from  the  men  who  brought  the  patient,  and  of  course  nothing  could  be 
learned  from  the  patient  himself.  He  died  during  the  early  hours  of  the 
morning.  On  making  inquiries  from  the  keeper  of  the  small  boarding- 
house  where  the  man  had  lodged,  nothing  more  definite  could  be  learned 
than  that  he  was  a  laborer,  and  had,  probably,  worked  at  some  of  the  ex- 
cavations along  the  railroad.  The  day  before  the  man  was  sent  to  the 
asylum,  after  two  or  three  days'  residence  in  the  boarding-house,  he  was 
taken  sick ;  complained  of  drowsiness,  loss  of  appetite,  and  general  weak- 
ness. His  condition  gradually  became  worse,  and  the  next  morning  he 
fell  into  a  comatose  condition  from  which  he  never  rallied.  The  post- 
mortem examination  was  made  September  13th,  at  9  A.  M.,  five  hours 
after  death. 

Body  large ;  tolerably  well  nourished ;  anterior  surface  of  the  body 
pale,  on  the  posterior  surface  a  good  deal  of  post-mortem  congestion  ;  no 
oedema.  Scalp  pale ;  skull  of  ordinary  thickness  ;  dura  mater  lightly 
adherent ;  pia  mater  slightly  thickened  and  oedematous,  easily  stripped  off 
from  the  surface  of  the  brain.  The  cortex  of  the  brain  was  throughout  of 
a  dull  chocolate  color.  This  color  seemed  more  pronounced  in  the  gray 
than  in  the  white  matter,  although  the  white  matter  was  slightly  darker 
than  normal ;  the  line  of  demarcation  separating  the  white  from  the  gray 
was  apparently  more  pronounced.  This  sharp  demarcation  gave  the  gray 
matter  the  appearance  of  being  lessened  in  width.  The  central  ganglia 
of  the  brain  partook  of  the  same  color  as  the  cortex.  The  pia  mater  of 
cord  hyperEemic  ;  the  cord  itself  darker  ;  the  gray  matter  of  the  same  color 
as  the  cerebral  cortex.  The  thyroid  small.  In  the  trachea  a  small 
quantity  of  mucus.  Its  mucous  membrane,  as  well  as  that  of  the  pharynx, 
larynx,  and  oesophagus,  very  pale  and  anaemic.  In  the  pericardial  cavity, 
a  slight  quantity,  about  l-|-oz.,  of  slightly  yellowish  serum.  Heart's  flesh 
firm  ;  its  valves  normal.  Both  lungs  intimately  adherent  to  the  pleura. 
Lung  tissue  inflated  and  contained  much  pigment.  At  the  anterior  edges 
of  both  lungs  there  was  a  slight  degree  of  emphysema.  The  peritoneum 
smooth  and  glistening;  liver  enlarged  (4  lbs.  12  oz.),  soft,  and  of  a  dark 
slaty  color  ;  on  cutting  its  tissue,  it  was  found  very  hyperaemic.  Spleen  was 
very  much  enlarged,  7  inches  long,  4  wide,  and  2  thick,  and  of  an  almost 
black  color,  with  a  tinge  of  gray.  Kidneys  of  ordinary  size,  capsule  easily 
stripped  off.  The  cortex  full  and  hypersemic ;  no  pigmentation  could  be 
made  out,  In  the  small  intestine,  fluid  contents  tinged  with  bile  ;  mucous 
membrane  normal.  Large  intestine  distended  with  gas  and  fecal  matter. 
Pancreas  of  ordinary  size,  color,  and  consistency  ;  stomach  empty,  its 
mucous  membrane  slightly  hyperaemic,  and  in  several  places  there  were 


418 


Councilman,  Abbott,  Malarial  Fever. 


[April 


small  hemorrhagic  erosions.  Supra-renal  capsules  in  no  way  changed. 
Bladder  slightly  distended.  The  voluntary  muscles  and  subcutaneous 
tissues  presented  no  abnormal  discolorations.  Small  portions  of  the  spleen, 
liver,  kidneys,  lung,  brain,  and  cord  were  placed  at  once  in  a  large  amount 
of  absolute  alcohol  for  microscopic  examination.  In  addition,  pieces  of 
the  brain  and  cord  were  placed  in  Muller's  fluid. 

Spleen  Microscopic  examination  showed  considerable  passive  conges- 
tion in  this  viscus.  There  was  a  large  amount  of  pigment  present,  which 
appeared  principally  under  two  forms.  In  one  form  the  pigment  granules 
were  large  and  irregular  in  shape,  though  generally  with  rounded  out- 
lines. The  pigment  was  of  an  intensely  dull  black  color.  These  irregular 
pigment  masses  were  of  various  sizes,  from  mere  granules  up  to  the  size  of 
a  white  blood-corpuscle  and  larger.  They  were  both  free  and  inclosed  in 
cells  which  were  apparently  white  blood-corpuscles.  The  second  form 
under  which  this  pigment  appeared  demands  special  consideration.  It 
was  inclosed  in  numerous  extremely  small  hyaline-looking  bodies.  The 
most  of  these  were  about  one-third  the  diameter  of  a  red  blood-corpuscle. 
They  were  generally  rounded,  but  sometimes  slightly  irregular  in  outline. 
They  seemed  to  be  composed  of  a  pale,  almost  hyaline,  or  very  slightly 
granular  substance,  which  was  stained  slightly  by  Bismarck  brown,  and 
gentiana  violet.  This  staining  was  so  slight  that  it  was  only  certainly 
seen  by  the  use  of  the  Abbey  illuminator  without  the  diaphragm,  thereby 
rendering  the  color  picture  much  more  apparent  than  when  the  Abbey 
was  used  with  diaphragm.  Within  these  small  masses  a  quantity  of  in- 
tensely black  pigment  was  seen,  which  assumed  various  forms.  When 
the  specimens  were  examined  with  a  ^th  homogeneous  immersion  without 
the  diaphragm,  it  appeared  in  most  cases  in  a  horse-shoe  shape,  similar  to 
the  nucleus  of  a  white  blood-corpuscle.  Sometimes  this  pigment  formed 
a  connected  mass,  at  others  it  took  the  form  of  a  collection  of  separate 
granules.  These  granules  were  so  small,  that  they  could  only  be  resolved 
with  lenses  of  the  highest  power.  In  most  cases  the  small  hyaline  bodies 
referred,  to  appeared  to  be  in  the  interior  of  red  blood-corpuscles,  usually 
at  their  margin.  Very  often  large  collections  of  blood-corpuscles  contain- 
ing these  masses  were  seen  ;  at  other  times  one  or  two  only  would  be  met 
with  in  the  field  of  the  microscope.  Seldom  more  than  one  was  found  in 
a  single  corpuscle.  In  a  few  cases,  however,  two  were  seen.  In  a  few 
instances  the  pigment  granules  seemed  to  be  arranged  in  the  bodies  in  a 
circlet.  In  all  cases,  there  was  no  irregular  distribution  of  the  pigment 
through  the  masses,  but  it  was  always  collected  together.  No  pigment 
was  found  in  the  trabecular  of  the  spleen.  There  were  some  large  swollen 
cells,  evidently  white  blood-corpuscles,  which  also  contained  the  hyaline 
bodies.  In  the  majority  of  cases,  these  large  cells  contained  the  large 
irregular  masses  of  pigment  first  mentioned. 

Liver  The  liver-cells  were  of  ordinary  size,  and  contained  rather 

more  than  the  usual  amount  of  bile  pigment.  In  the  capillaries  there 
was  a  great  quantity  of  pigment  in  the  form  of  the  large  irregular  masses 
described  in  the  spleen.  It  was  seldom  lying  free  in  the  vessels,  but  was 
for  the.  most  part  inclosed  in  large  cells.  These  cells  were  frequently  of 
an  enormous  size,  filling  up  the  capillary  bloodvessels  for  a  considerable 
distance.  They  were  composed  of  very  pale  protoplasm,  and  contained 
one  and  sometimes  two  irregularly  shaped  and  tolerably  brightly  stained 
nuclei.  They  were  generally  oblong,  conforming  to  the  shape  of  the  liver 
capillary.,  which  they  entirely  filled.    In  size,  many  were  three  or  four 


1885.] 


Councilman,  Abbott,  Malarial  Fever. 


419 


times  that  of  a  liver-cell,  others  were  very  much  smaller,  and  every  gra- 
dation could  be  seen  from  those  of  the  size  and  general  appearance  of  a 
leucocyte  up  to  the  large  masses  spoken  of.  Here  and  there  after  long 
search,  a  few  of  the  small  hyaline  masses,  spoken  of  in  the  spleen,  were 
found  both  within  red  blood-corpuscles  and  the  large  swollen  white  cor- 
puscles. 

Lungs. — In  the  lungs  there  was  so  much  of  the  ordinary  carbon  pig- 
ment present  that  but  little  could  be  said  with  certainty  about  the  other 
pigment;  still,  without  doubt,  there  was  a  good  deal  of  the  latter  contained 
within  the  bloodvessels  of  the  alveoli,  in  cells  similar  to  the  large  cells 
spoken  of  in  the  liver  and  spleen. 

Kidneys. — The  epithelium  of  the  convoluted  tubules  was  swollen  and 
granular,  in  many  cases  entirely  filling  the  lumen.  There  was  a  slight 
degree  of  small  cell  infiltration  around  the  glomeruli  and  in  other  places. 
The  staining  of  the  nuclei  of  the  convoluted  tubules  was  often  dimmed  in 
consequence  of  the  extremely  granular  condition  of  the  protoplasm.  A 
considerable  amount  of  pigment  was  found  in  the  vessels  of  the  glomeruli, 
and  in  vessels  of  larger  calibre  which  were  seen  in  cross  section.  This 
pigment  was  all  contained  in  large  cells.  None  of  the  small  hyaline 
bodies  spoken  of  elsewhere  were  found  here. 

Brain  On   microscopic  examination  this  presented  a  remarkable 

appearance  ;  with  a  low  power  the  bloodvessels  appeared  as  if  they  were 
artificially  injected  with  a  black  injecting  mass.  On  closer  examination 
with  an  ordinary  power  of  three  hundred  diameters,  they  appeared  to  be 
filled  with  very  small  granules  of  pigment.  By  the  use  of  very  high 
powers  (oil  immersion  ^  and  Abbey  illuminator),  the  pigment  was  found 
to  be  almost  entirely  contained  in  the  small  hyaline  protoplasmic  masses 
spoken  of  in  the  spleen.  These  lay  exclusively  within  the  capillaries  ; 
sometimes  they  were  inclosed  in  the  bodies  of  red  blood-corpuscles,  some- 
times they  were  free.  From  the  great  numbers  of  these  masses  in  the 
brain  they  could  be  studied  better  here  than  in  any  other  place.  It  could 
be  distinctly  seen  that  they  were  stained  and  appeared  to  be  composed  of 
a  hyaline  or  very  finely  granular  substance.  Their  diameter,  as  said 
before,  was  about  one-third  that  of  a  red  blood-corpuscle.  The  pigment 
within  them  presented  the  same  appearance  and  arrangement  as  in  the 
spleen.  In  some,  the  circular  arrangement  of  the  pigment  granules  was 
very  obvious.  There  was  scarcely  a  capillary  in  the  gray  substance  of 
the  brain  that  did  not  contain  these  bodies  in  greater  or  less  numbers. 
Some  of  the  vessels  were  filled  with  them,  and  no  blood-corpuscles  could 
be  seen.  Others  contained  both  the  hyaline  masses  and  blood-corpuscles. 
At  various  places  in  stainings,  made  both  with  Bismarck  brown  and  gen- 
tiana  violet,  hyaline  masses  were  found  containing  no  pigment,  which 
stained  in  the  same  way  and  were  of  the  same  shape  and  size  as  those 
which  contained  the  pigment.  Others  were  found  which  contained  but 
one  or  two  pigment  granules.  The  white  substance  of  the  brain  also  con- 
tained these  pigmented  hyaline  masses,  but  in  much  smaller  numbers. 
The  ganglion-cells  stained  in  the  ordinary  manner,  and  there  appeared  to 
be  no  change  in  the  histological  structure  of  the  brain. 

In  the  specimens  examined  after  hardening  in  Miiller's  fluid,  the  pig- 
ment was  very  perceptible,  but  the  hyaline  masses  were  very  difficult  to 
make  out.  In  these  specimens  another  thing  was  noticed  which  was  not 
apparent  in  the  specimens  hardened  in  alcohol.  Numerous  very  small 
hemorrhages  were  found  along  the  course  of  the  vessels  ;  sometimes  but 


420 


Councilman,  Abbott,  Malarial  Fever. 


[April 


one  or  two  red  blood-corpuscles  seemed  to  have  escaped,  at  others  the 
hemorrhage  was  much  larger.  It  is  most  remarkable  that  in  these  hemor- 
rhages none  of  the  pigmented  hyaline  masses  nor  any  free  pigment  was 
found. 

Cord  The  cord  presented  the  same  general  microscopic  characters  as 

the  brain.  The  bloodvessels  were  filled  with  the  pigmented  hyaline 
masses,  which  appeared  to  be  more  numerous  in  the  gray  than  in  the  white 
matter.  The  blood-corpuscles  in  sections,  both  of  the  brain  and  spinal 
cord,  appeared  to  have  retained  their  normal  aspect ;  even  when  they 
contained  the  pigmented  bodies  they  were  no  paler  than  normal. 

Case  II — Wm.  Burr,  set.  67  years  ;  occupation  laborer  ;  born  in  Mass.  ; 
admitted  April  22,  1884;  died  October  9,  1884.  He  came  into  the  hos- 
pital on  the  above-named  date  suffering  with  asthma,  which  he  had  had 
at  intervals  for  several  years.  He  remained  under  treatment  until  May 
13th,  at  which  time  he  had  sufficiently  recovered  to  be  transferred  to  the 
"  chronic  wards."  From  this  time  until  he  died  he  enjoyed  good  health, 
was  able  to  assist  the  ward  master  in  his  daily  duties,  and  ate  heartily 
every  day.  The  first  symptom  of  his  last  attack  was  the  flighty  condi- 
tion of  his  mind  ;  this  gradually  grew  worse,  and  at  the  end  of  seven  days 
he  was  in  profound  coma  and  died.  While  in  hospital  his  urine  was  albu- 
minous, Bright's  disease  had  consequently  been  diagnosed,  and  his  present 
attack  was  supposed  to  be  one  of  urremic  coma. 

Post-mortem  made  a  few  hours  after  death.  Body  large,  strongly  built ; 
muscular  tissue  well  developed  ;  subcutaneous  adipose  tissue  scanty  ;  ante- 
rior surface  of  body  pale  ;  posteriorly,  some  amount  of  congestion  ;  scalp 
pale;  skull  of  ordinary  thickness  and  pale;  dura  mater  adherent;  pia 
mater  hypersemic . 

The  brain  cortex  presented  exactly  the  same  appearance  as  in  the  pre- 
ceding case.  It  was  of  a  dark  chocolate  color  ;  ventricles  of  brain  slightly 
distended  with  clear  serum  ;  meninges  of  cord  slightly  hypersemic  ;  cord 
itself  darker  than  normal,  especially  the  gray  columns  of  the  same,  which 
stood  out  in  bold  contrast  with  the  white.  Mucous  membrane  of  the 
larynx,  pharynx,  and  oesophagus  pale  ;  a  slight  quantity  of  mucus  in  the 
trachea ;  thyroid  small  ;  both  lungs  free  from  adhesions,  posterior  portion 
of  lungs  very  hypersemic.  On  pressing  the  lung  substance  a  slight 
amount  of  pus  could  be  squeezed  from  the  smaller  bronchi.  Mucous  mem- 
brane of  bronchi  red  and  congested.  There  was  a  slight  degree  of  ec- 
centric hypertrophy  of  left  ventricle  of  the  heart.  Heart's  flesh  firm,  its 
valves  normal.  The  liver  enlarged,  weight  three  pounds,  fourteen  ounces, 
and  of  a  dark  grayish  color.  On  section,  considerable  blood  escaped. 
Spleen  enlarged,  weight  one  pound  nine  ounces,  and  so  soft,  that  when 
taken  in  the  hand  it  felt  like  a  bladder  full  of  fluid.  It  was  intensely  con- 
gested and  of  a  dark,  almost  black,  color. 

Kidneys  of  ordinary  size,  capsule  in  some  places  adherent,  so  that  on 
pulling  it  off,  portions  of  the  kidney  substance  were  torn  away  with  it. 
Tissue  of  the  kidneys  firmer  than  normal,  cortex  slightly  diminished  in 
thickness.  Intestines  slightly  distended.  In  the  right  tunica  vaginalis 
was  a  hydrocele  as  large  as  a  lemon.  Marrow  of  long  bones  appeared 
normal. 

Microscopic  examinations  at  the  time  of  the  post  mortem  were  made 
of  scrapings  from  the  marrow  of  the  bones,  and  of  blood  taken  from  the 
right  heart.  In  the  bone  marrow  a  slight  amount  of  pigment  was  found, 
both  free  and  inclosed  in  cells.  The  blood,  which  was  of  a  laky  color, 
contained  here  and  there  pigment  granules  inclosed  in  white  corpuscles. 


1885.] 


Councilman,  Abbott,  Malarial  Fever. 


421 


Portions  of  the  brain,  cord,  lung,liver,  spleen,  and  kidneys  were  placed 
at  once  in  a  large  amount  of  absolute  alcohol.  Portions  of  the  nervous 
tissues  were  also  hardened  in  Miiller's  fluid.  An  examination  of  the 
brain  showed  the  capillaries  of  the  gray  and  white  matter,  but  especially 
the  former,  to  be  filled  with  small  masses  of  pigment.  Examination  with 
higher  power,  ^  oil  immersion  and  Abbey  illuminator,  showed  the 
pigment  to  be  contained  in  the  small  hyaline  masses  described  in  Case 
I.  It  was  distinctly  seen  that  these  bodies  stained  with  Bismarck  brown. 
Sections  of  the  brain  were  also  examined  both  in  glycerine  and  in  water 
without  staining.  In  the  sections  mounted  in  glycerine  these  hyaline 
bodies  could  only  be  seen  with  the  greatest  difficulty  ;  this  was  evidently 
due  to  the  similarity  of  their  index  of  refraction  to  that  of  the  glycerine. 
In  sections  mounted  in  water,  on  the  other  hand,  they  were  very  easily 
seen  and  appeared  to  be  composed  either  of  homogeneous  or  very  finely 
granular  protoplasm.  In  size  they  varied  from  the  one-fourth  to  one-half 
of  that  of  a  red  blood-corpuscle.  The  pigment  contained  in  them  assumed 
various  forms — sometimes  that  of  a  stellate  figure,  at  other  times  that  of 
a  cross  ;  and  some  figures  appeared  not  unlike  the  figures  in  a  nucleus  when 
it  is  undergoing  division. 

Especial  stress  should  be  laid  on  the  regularity  in  the  size  of  the  hya- 
line bodies,  and  the  general  agreement  in  character  of  the  pigment  con- 
tained in  them.  Generally,  the  vessels  were  not  distended  with  red  blood- 
corpuscles,  nor  were  the  hyaline  masses  so  often  contained  in  these,  as  was 
the  case  in  Case  I. 

The  spleen  was  so  crowded  with  lymphoid  cells  and  red  blood-corpus- 
cles that  it  was  difficult  to  study  closely  the  finer  histological  details.  In 
numerous  places,  however,  especially  in  the  well-defined  bloodvessels,  an 
arrangement  of  pigment  could  be  made  out  in  all  respects  identical  with 
that  in  the  brain.  Small  hyaline  masses,  which  stained  faintly  with  the 
anilines,  were  seen,  sometimes  encased  in  red  blood-corpuscles,  at  other 
times  lying  between  them. 

In  addition  to  these,  the  ordinary  larger  or  smaller  irregular  masses  of 
pigment  were  found,  sometimes  free,  sometimes  inclosed  in  large  cells. 

In  the  liver  the  quantity  of  pigment  was  much  less  than  in  the  brain 
and  spleen  ;  only  the  irregular  masses  of  it  were  found  in  the  capillaries 
inclosed  in  large  cells  similar  to  those  spoken  of  in  Case  I. 

Kidney — In  the  kidney  the  epithelium  of  the  convoluted  tubules  was 
swrollen  and  granular.  On  examination  with  high  power  the  epithelial 
cells  in  many  places  were  found  to  be  converted  into  large  granular  masses 
in  which  there  was  no  trace  of  a  nucleus.  This  change  was  confined  solely 
to  the  convoluted  tubules.  Immediately  beneath  the  capsule  and  in  a  few 
other  places,  some  of  the  glomeruli  were  shrunken  and  converted  into 
fibrous  masses.  In  other  places  there  was  only  a  thickening  of  the  cap- 
sule of  the  glomerulus.  This  change  was  by  no  means  general  in  the  kid- 
ney ;  in  most  places  the  glomeruli  were  completely  unchanged ;  at  two  or 
three  points  there  was  a  considerable  amount  of  small  cell  infiltration. 
Numerous  casts  were  found  both  in  the  tubes  of  Henle  and  in  the  collect- 
ing tubes.  The  pigmentation  of  the  tissues  was  most  evident  even  under 
a  very  low  power.  The  pigment  seemed  here  to  be  distributed  with 
more  irregularity  than  in  any  other  organ  examined.  It  was  found  in 
the  bloodvessels,  in  the  effused  blood  at  one  or  two  points  of  hemorrhage, 
and  especially  in  the  glomeruli.  It  was  both  free  and  inclosed  in  large 
cells.  None  of  the  small  hyaline  masses  were  found  at  any  point,  although 
a  most  careful  search  was  made  for  them. 


422  Councilman,  Abbott,  Malarial  Fever.  [April 

The  lungs  showed  a  slight  amount  of  bronchitis,  with  a  slight  cellular 
exudation  into  some  of  the  alveoli  immediately  in  the  vicinity  of  the  small 
branchioles.  Pigment  was  found  here  in  the  bloodvessels.  It  couid  not 
be  said  with  certainty  whether  the  pigment  lying  in  the  tissues  outside 
the  capillaries  was  the  malarial  pigment  or  the  ordinary  carbon  pigment 
of  the  lungs. 

"We  have  described  these  two  cases  in  full,  and  it  will  be  found  that  the 
gross  pathological  lesions  agree  in  every  detail  with  the  lesions  found  in 
the  comatose  form  of  malarial  fever  described  by  French  authors.  A 
case  of  this  form  of  fever,  with  a  full  account  of  the  autopsy,  was  pub- 
lished by  Dr.  Meigs,  and  referred  to  at  length  by  Dr.  Sternberg  in  his 
valuable  treatise  on  malaria.1  In  this  case,  reported  by  Meigs,  an  un- 
known man  was  brought  to  hospital  in  an  absolutely  unconscious  con- 
dition, from  which  he  could  not  be  aroused.  No  further  history  could  be 
obtained,  except  that  he  came  from  a  southern  malarious  district,  and  had 
been  suffering  from  fever.  At  the  autopsy,  made  four  hours  after  death, 
the  brain  was  found  to  be  of  a  chocolate-gray  color.  On  its  section  sur- 
face the  delicate  tortuous  vessels  appeared  abnormally  distinct,  and  the 
white  substance  throughout  was  of  a  dull,  dirty-gray  color.  Dr.  Meigs 
remarks,  concerning  the  microscopic  appearance  of  the  tissues  : — 

' '  I  have  never  before  seen  a  brain  presenting  such  an  appearance  ;  it  was  leaden- 
colored  throughout,  as  long  ago  described  by  Morgagni,  who  is  quoted  at 
length  by  Frerichs.  The  hue  of  the  gray  matter  was  most  singular.  It  looked 
as  though  it  had  been  washed  over  with  a  not  very  weak  solution  of  India  ink. 
I  examined  my  specimens  with  the  microscope.  In  every  one  of  these,  all  the 
capillaries  were  unusually  distinct,  and  were  crowded  with  a  black  pigment  in 
the  form  of  granules,  lying  in  the  calibre,  or  deposited,  apparently,  in  the  walls 
themselves.  There  existed,  also,  scattered  through  the  cortical  brain  substance, 
isolated  grains  of  pigment  much  too  large  to  be  embraced  in  a  capillary  tube. 
It  was  evident  that  the  general  dark  color  of  the  cerebral  tissue  and  substance  of 
the  spinal  cord  was  due  to  the  aggregation  of  these  minute  grains  and  granules. 
Wherever  the  blood  had  gone,  it  had  taken  the  pigment,  filling  the  capillaries, 
and  lodged  it  in  the  tissues.  To  the  naked  eye,  and  more  particularly,  to  the 
eye  aided  by  a  pocket  lens,  the  fine  vessels  of  the  white  medullary  matter  were 
everywhere  visible,  resembling,  as  Dr.  Bright  aptly  remarks,  '  the  appearance 
produced  by  scraping  the  nap  of  fine  cloth  on  a  sheet  of  white  paper.'  The  color 
of  the  liver  was  an  olive  green.  The  term  '  bronzed  liver'  employed  by  Dr. 
Thos.  Stewardson,  in  his  paper  on  Bilious  Fever,  most  correctly  expresses  this 
appearance." 

According  to  Frerichs,2  sometimes  severe  brain  symptoms,  which  speed- 
ily prove  fatal,  are  developed  after  only  a  few  hours  of  vague  indisposition, 
without  any  distinct  febrile  symptoms  manifesting  themselves.  In  other 
cases,  a  simple  intermittent  fever  has  existed  for  weeks  or  months,  when 
suddenly  a  severe  fit  comes  on,  which  often  terminates  fatally  in  an 
instant. 

The  first  case  reported  agrees  almost  entirely,  in  its  history  and  its 
gross  pathological  appearances,  with  that  described  by  Meigs. 

1  Malaria  and  Malarial  Diseases,  p.  177. 

2  Referred  to  from  Sternberg. 


1885.]  Councilman,  Abbott,  Malarial  Fever. 


423 


In  the  second  case,  there  was  no  history  of  malarial  toxaemia,  and  the 
man  had  been  a  resident  of  the  almshouse  since  April. 

Cases  of  malarial  fever  among  the  physicians  and  inmates  of  the  asy- 
lum, having  an  origin  in  the  asylum,  are  not  uncommon  ;  but  cases  of  the 
comatose  form  are  uncommon,  both  in  the  asylum  and  in  the  surrounding 
country. 

It  is  worthy  of  notice  that  a  coma  of  this  sort  can  be  mistaken  for 
ursemic  coma,  especially  when  the  existence  of  kidney  trouble  was  denoted 
by  an  albuminous  urine. 

That  these  two  cases  were  cases  of  malarial  coma,  the  post-mortems  leave 
no  doubt.  Of  especial  interest  in  this  connection  are  the  small  hyaline 
masses  which  were  found,  particularly  in  the  brain  and  elsewhere. 

Laveran1  has  described  certain  organisms  in  the  blood  and  in  the  tissues 
of  malarial  fever  patients  which  lead  us  to  think  that  he  has  seen  the 
hyaline  masses  described  by  us.  He  describes  these  bodies,  which  he  says 
exist  in  the  blood  of  all  patients  sick  of  malarial  fever  who  have  not  taken 
quinine  for  a  long  time,  when  seen  under  a  power  of  400  or  500  diame- 
ters, as  being  of  three  varieties. 

Bodies  No.  1  These  bodies  are  elongated,  and  often  curved  as  a 

crescent,  though  some  are  oval.  Their  length  is  8  to  9  and  the 
width  3  fx  ;  their  contour  is  very  delicate  and  colorless,  except  where 
pigment  granules  are  contained  in  them:  These  grains  of  pigment  have 
often  a  regular  distribution  in  the  mass.  In  blood  treated  with  osmic 
acid  and  preserved  in  picro-carminate  of  glycerine,  it  is  seen  that  these 
bodies  have  a  double  contour,  and  that  the  central  part  stains  a  rosy  color, 
more  pale  than  the  leucocytes  in  the  same  preparation.  They  are  without 
motion. 

Body  No.  2  is  described  as  an  organism  which  presents  a  different  as- 
pect according  as  it  is  in  motion  or  at  rest.  In  a  state  of  repose  one  sees 
a  body  a  little  larger  than  a  red  blood-corpuscle.  In  the  interior  of  this 
body  the  grains  of  pigment  are  regularly  arranged  in  a  circlet,  the  pig- 
ment appearing  as  minute  black  pearls.  When  in  motion,  very  delicate 
filaments  are  seen,  which  are  rapidly  moved  in  every  direction,  and  which 
are  attached  to  the  organism.  The  length  of  these  filaments  is  three  or 
four  times  the  diameter  of  a  red  blood-corpuscle,  and  they  are  three  or 
four  in  number.  Sometimes  the  filaments  become  freed  from  the  pig- 
mented body,  and  continue  to  move  in  the  blood. 

Body  No.  3  is  described  as  an  organism  which  is  spherical  in  its  primi- 
tive form,  but  great  variations  in  its  shape  and  dimensions  are  found.  It 
contains  pigment,  arranged  in  a  circlet,  as  in  No.  2. 

He  says,  besides  these  bodies  Nos.  1 ,  2,  and  3,  one  finds  in  the  blood 
small,  brilliant,  round,  mobile  bodies  without  specific  characters,  and 

1  Nature  Parasitaire  des  Accidents  de  l'lmpaludisme,  etc.    Paris3  1883. 


424 


Councilman,  Abbott,  Malarial  Fever. 


[April 


grains  of  pigment  of  a  fiery  red  or  clear  blue  color.  This  blue  pigment 
appears  to  result  from  a  transformation  of  the  red. 

He  gives  the  details  of  four  cases  in  which  the  organs  were  examined 
after  death  and  in  which  these  pigmented  bodies  were  seen.  All  of  these 
cases  died  in  coma.  The  brain  was  of  a  chocolate  color,  and  the  spleen 
and  liver  presented  the  characteristic  appearances.  The  pigmented  bodies 
were  found  in  every  tissue  examined.  Some,  he  says,  were  as  large  as  a 
leucocyte  ;  most,  however,  were  from  one-third  to  one-fourth  that  size.  He 
gives  various  figures  of  the  pigmented  bodies,  which  he  thinks  are  low  organ- 
isms belonging  to  the  infusoria.  At  first  sight  he  was  inclined  to  think  that 
they  belonged  to  the  amoeba,  but  has  given  up  this  idea  from  seeing  the  fila- 
ments in  motion.  He  thinks  the  bodies  belong  to  the  oscillatoria,  and  has 
given  them  the  name  of  Oscillatoria  Malariae.  That  the  oscillatoria  in  general 
play  a  certain  part  in  the  production  of  malaria  he  thinks  probable,  and 
cites  the  case  from  Schurtz1  of  a  man  engaged  in  the  study  of  cryptogams 
acquiring  malarial  fever  after  sleeping  in  a  room  filled  with  oscillatoria?. 

Kelsch2  calls  attention  to  the  presence  of  pigmented  bodies  in  the  blood 
of  all  patients  affected  with  malarial  fever,  during  the  paroxysm,  and 
thinks  that  their  presence  or  absence  should  serve  as  a  diagnostic  mark. 
Those  bodies  described  by  Kelsch  are  similar  to  bodies  No.  3  described  by 
Laveran. 

From  the  description  which  Laveran  has  given,  and  from  an  examina- 
tion of  his  plates,  it  is  difficult  to  avoid  the  conclusion  that  the  bodies 
which  he  has  described  were  leucocytes  filled  with  particles  of  pigment. 
The  filaments  could  very  well  have  been  threads  of  fibrin  clinging  to  these. 
From  his  figures  of  the  tissues  one  is  led  to  the  same  conclusion. 

Richard,3  who  has  made  extensive  observations  of  the  blood  and  tissues 
of  malarial  patients  in  the  hospital  at  Phillipiville,  confirms  Laveran's 
discovery,  though  his  description  of  the  microbe  differs  considerably  from 
that  of  Laveran  and  approaches  more  nearly  to  what  we  have  seen.  The 
microbe,  he  says,  has  a  special  habitat,  the  red  corpuscle  of  the  blood,  in 
which  it  dwells,  somewhat  as  the  weevil  in  a  pea.  In  some  cases  red  cor- 
puscles are  met  with  which  have  a  small  round  clear  pocket,  with  which 
exception  the  corpuscle  retains  its  normal  appearance  ;  it  is  simply  stung, 
so  to  speak.  Along  with  these  corpuscles  others  are  seen  in  which  the 
microbe  has  reached  a  more  advanced  form.  In  the  clear  spot,  a  series  of 
small  pigment  granules  are  seen,  around  which  the  haemoglobin,  easily 
recognized  by  its  color,  forms  a  ring  which  retracts  as  the  parasite  in- 
creases in  volume.  Finally  a  stage  is  reached  when  there  is  only  a  small 
colorless  margin  around  the  parasite,  the  haemoglobin  having  entirely  dis- 

*  Arch,  der  Heilkunde,  186S. 

2  Contribution  a  PHistoire  des  Maladies  Palustres.  Arch.  Gen.  de  Medecine,  Oct. 
1880. 

3  Comp.  Rend.  Acad.  d.  Sc.  Paris,  1882,  xciv.  p.  496. 


1885.] 


Councilman,  Abbott,  Malarial  Fever. 


425 


appeared,  and  the  corpuscle  being  reduced  to  a  small  envelope  which  en- 
circles the  parasite.  In  this  form  it  is  identical  with  body  No.  2  described 
by  Laveran.  The  appearance  seen  by  him  in  the  red  corpuscles  he  thinks 
represents  the  first  stage  in  the  evolution  of  the  parasite,  a  stage  which 
escaped  the  attention  of  Laveran. 

It  is  evident  that  Richard  has  observed  the  same  appearance  that  we 
have  seen,  especially,  in  the  red  corpuscles  in  the  brain  ;  and  an  observa- 
tion of  Herz,  in  which  he  avers  that  he  has  found  nucleated  red  corpuscles 
in  the  blood  of  malarial  fever  patients,  makes  it  seem  probable  that  he  has 
seen  a  similar  condition. 

In  neither  of  the  cases  which  we  have  described  was  an  opportunity 
given  for  an  examination  of  the  blood  during  life.  Examinations  of  blood 
were,  however,  made  in  several  other  cases  of  malarial  fever,  and  negative 
results  were  obtained.  In  one  of  the  cases  small  round  masses,  somewhat 
similar  to  the  hyaline  masses  which  we  have  described,  were  found  free  in 
the  blood.  They  were,  however,  not  pigmented.  They  were  regarded  by 
us  as  small,  masses  of  protoplasm  resulting  from  the  breaking  down  of 
white  blood-corpuscles. 

What  is  the  nature  of  these  hyaline  bodies  that  we  have  described  ? 
Are  they  organisms  of  the  same  nature  as  those  described  by  Laveran  and 
Richard,  or  do  they  result  from  some  metamorphosis  of  the  cells,  possibly 
the  red  blood-corpuscles  under  the  action  of  the  malarial  poison  ? 

There  are  several  facts  which  would  speak  rather  strongly  in  favor  of 
their  being  lower  organisms. 

The  first  is  their  perfect  regularity  in  size  and  shape.  In  all  cases 
where  they  were  found,  both  within  and  outside  of  the  red  blood-corpus- 
cles, they  varied  but  slightly.  Certainly  not  more  than  individual  bacilli 
or  micrococci  of  the  same  species  would  vary.  Another  strong  point  is 
the  fact  of  their  staining;  with  the  aniline  colors.  Though  the  amount  of 
staining  they  underwent  was  slight,  it  was  still  perfectly  apparent. 

The  red  blood-corpuscles,  it  is  true,  will  stain  with  some  of  the  red 
aniline  colors,  particularly  with  eosin,  and  the  acid  fuchsin  used  in 
staining  nervous  tissues.  It  is,  however,  absolutely  known  that  neither 
Bismarck  brown  nor  gentiana  violet  has  the  slightest  staining  action  on 
them.  It  is  possible  that  some  metamorphosis  might  take  place  in  the  red 
corpuscles,  which  would  result  in  a  condensation  of  the  haemoglobin  in  a 
small  mass.  The  action  of  tannin  on  human  blood  and  of  borax  on  the 
frog's  blood  will  produce  such  a  condensation  in  one  part  of  the  corpuscle, 
leaving  the  remainder  perfectly  pale ;  but  the  condensed  haemoglobin  pro- 
duced by  these  reagents  does  not  stain  with  Bismarck  brown  and  gentiana 
violet. 

In  our  case,  in  sections  of  the  brain  hardened  in  Miiller's  fluid,  by  which 
the  normal  color  of  the  corpuscle  is  to  a  great  extent  preserved,  it  was  per- 
fectly apparent  that  the  red  corpuscles,  even  those  containing  the  hyaline 


426 


Councilman,  Abbott,  Malarial  Fever. 


[April 


bodies,  were  not  decolorized.  Another  point  is  their  being  found  in  the 
brain,  only  in  the  vessels  ;  where  there  was  a  hemorrhage  into  the  sub- 
stance of  the  brain  they  were  not  found  in  the  extravasated  blood-corpus- 
cles. Were  they  due  to  any  action  taking  place  in  the  corpuscles  them- 
selves it  is  difficult  to  see  why  those  corpuscles  outside  of  the  vessels 
should  not  have  undergone  the  same  change  as  those  within  the  vessels. 

We  are  possibly  too  prone  to  look  to  only  one  class  of  lower  organisms, 
— the  Bacteria, — as  the  pathogenic  factors  in  infectious  diseases. 

As  Koch  has  pointed  outfit  is  perfectly  just  to  suppose  that  we  can 
have  other  organisms  besides  bacteria  as  etiological  factors. 

On  the  other  hand,  there  are  strong  arguments  against  the  supposition 
that  these  hyaline  bodies  are  living  organisms. 

They  were  only  found  in  certain  organs  of  the  body,  and  here,  in  the 
vessels  ;  it  is  difficult  to  conceive  the  possibility  of  an  organism  existing  in 
the  blood  and  carried  as  an  inert  piece  of  matter  in  the  circulation,  being 
heaped  up  in  the  capillaries  of  one  part,  as  these  were  in  the  capillaries  of 
the  brain,  and  not  in  those  of  another.  Why  were  they  not  found  in  the 
glomeruli  of  the  kidneys,  and  in  greater  numbers  in  the  liver?  In  the 
latter,  as  stated,  they  were  only  found  in  isolated  instances  in  Case  I., 
and  not  at  all  in  Case  II.,  and  yet  we  know  that  these  organs  are  espe- 
cially the  ones  in  which  insoluble  matters  carried  with  the  blood  stream 
are  most  apt  to  stick.  It  can  hardly  be  supposed  that  an  insoluble  sub- 
stance in  the  blood  can  have  a  special  affinity  for  a  particular  organ  and  be 
collected  there.  They  were  so  small  that  they  could  pass  readily  through 
any  capillary  in  the  body.  But  if  they  result  from  any  change  in  the  red 
corpuscles  in  a  congested  area,  why  were  they  not  met  with  elsewhere  in 
other  congested  organs  ?  Numerous  other  pathogenic  organisms  have 
been  described  by  various  observers  in  malarial  fever. 

Salisbury  was  about  the  first  to  enter  upon  this  field.  He  described  in 
the  blood  of  persons  affected  with  malarial  fever  an  organism  belonging  to 
the  unicellular  algas.  This  he  describes  as  a  palmella,  and  claims  to  have 
produced  malarial  fever  in  persons  by  having  them  sleep  in  rooms  contain- 
ing fresh  earth  infested  with  this  organism.  These  statements  of  Salisbury 
have  now  only  a  slight  historical  value;  they  were  never  confirmed  by  any 
other  observers,  with  the  exception  of  Salisbury's  friend  and  disciple, 
Ephraim  Cutter,  of  Boston.  Lanzi  investigated  microscopically  the  flora 
and  fauna  of  the  marshes  of  the  Campagna  and  the  Pontine  marshes.  He 
describes  a  peculiar  alteration  that  the  algae  undergo  in  these  localities. 
Dark  granules  are  found  in  the  endochrome  of  the  cells,  which  become 
more  and  more  abundant  as  the  algae  die  until  they  completely  fill  the  cells 
and  give  them  a  black  color.  In  the  fall  of  the  year,  when  the  vegetation 
dies,  the  microscope  reveals  the  black  pigment  everywhere  in  the  vegetable 


1  Mittheilun^en  aus  dem  Gesundheitsamt,  vol.  i. 


1885.] 


Councilman,  Abbott,  Malarial  Fever. 


427 


debris  of  marshy  districts.  Lanzi  believes  that  the  granules  possess  the 
properties  of  a  ferment.  They  are  found  abundantly  in  the  dust  of  the 
Campagna,  and  pure  cultivations  of  them  in  suitable  culture  media  can 
easily  be  made.  He  believes  them  to  be  a  form  of  spherobacteria.  He 
thinks  the  pigment  found  in  the  organs  is  identical  with  this  pigment,  and 
that  melana3mia  is  produced  by  the  heaping  up  of  these  granules  in  the 
blood. 

Afanassieur  believes  that  the  small  granules  of  pigment  represent  a 
chromogenic  bacterium,  which  is  the  etiological  factor  in  the  production 
of  malarial  fevers. 

The  most  important  publication,  or  rather  the  publication  to  which  the 
most  importance  has  been  given  in  recent  years,  is  that  of  Klebs  and 
Tommasi-Crudeli  on  the  "  Origin  of  Malarial  Fever."  The  observers 
found  in  the  earth  of  malarial  districts  certain  bacteria,  one  of  which,  a 
bacillus,  they  supposed  to  be  the  essential  cause  of  malarial  fever.  This 
organism,  which  they  named  the  Bacillus  Malaria,  they  cultivated,  and 
claimed  to  have  produced  the  disease  in  rabbits  by  inoculation  with  the 
pure  culture.  Sternberg  has  repeated  in  every  respect  the  experiments  of 
these  authors,  and  has  in  no  wise  confirmed  their  results,  nor  have  they 
been  confirmed  by  any  other  experienced  mycologist. 

Marchiafava  has  found  the  organism  described  by  Klebs  and  Crudeli 
in  the  blood  taken  from  the  spleen  during  a  paroxysm. 

Still  other  organisms  have  been  reported  as  existing  either  in  the  ground 
in  regions  where  malaria  is  endemic,  or  in  the  blood  and  tissues  of  the 
patients ;  but  little  weight  need  be  attached  to  them. 

With  a  view  of  shedding  some  light  on  the  subject  of  lower  organisms 
in  malaria,  a  careful  search  for  the  bacilli  of  Klebs  and  Tommasi-Crudeli 
and  for  any  other  lower  organisms  was  made  in  all  of  the  cases  of  mala- 
rial fever  which  have  come  under  our  observation  on  the  post-mortem 
table.  Most  of  these  cases  had  died  of  some  other  disease  contracted 
during  or  before  the  malarial  attack.  Some  had  certainly  died  of  malarial 
fever.  The  organs  were  taken  from  the  body  a  few  hours  only  after  death, 
and  before  any  putrefactive  changes  had  taken  place.  Small  pieces  of 
brain,  liver,  lung,  spleen,  and  kidneys  were  placed  in  absolute  alcohol,  and 
stained  with  various  reagents  and  by  various  methods.  No  one  aniline 
color  was  used  ;  most  often  Bismarck  brown,  gentian  violet,  and  methylene 
blue  were  tried.  Sometimes  the  sections  were  stained  quickly  ;  at  others 
they  were  exposed  to  the  action  of  the  staining  reagents  for  a  considerable 
time  and  washed  out  thoroughly  in  alcohol.  The  microscopic  examina- 
tion was  made  with  oil  immersion  glasses  of  high  power  and  an  Abbey 
illuminator.  In  no  case  were  any  bacilli,  bacteria,  or  micrococci  found. 
Only  in  the  two  comatose  cases,  which  have  been  fully  described,  were 
the  singular  hyaline  bodies  found. 


[April 


Section  of  the  brain  cortex  from  Case  II.   The  capillaries  are  seen  filled  with  pigmeut.  X  125- 


Fig.  2. 


A.  Capillary  vessel  of  brain  filled  with  the  pigmented  hyaline  bodies.  B.  Section  of  a  small 
vein  in  the  spleen.  The  hyaline  bodies  are  seen  generally-inclosed  in  a  red  blood-corpuscle. 
The  ordinary  black  pigment  in  round  masses  is  seen  both  free  in  the  vessel  and  inclosed  in  two 
leucocytes.  In  both  the  brain  and  spleen  some  of  the  hyaline  bodies  are  seen  without  pigment. 
X  800  by  JL  oil  immersion  and  slightly  reduced. 


Fig.  3. 


A0A.D&1. 

Section  of  liver  from  Case  I.   The  beam  work  of  liver  tissue  is  seen,  and  in  the  capillaries,  the 
large  pale  pigmented  leucocytes.    X  500. 


1885.]    Knapp,  Observations  on  Cutaneous  and  Deep  Reflexes.  429 


This  is  another  argument  against  the  probability  of  these  being  micro- 
organisms. We  cannot  suppose  the  comatose  form  of  malarial  poisoning 
to  be  a  special  disease,  and  were  a  lower  organism  found  in  this,  we 
should  also  find  it  in  other  cases. 

We  present  here  the  facts  only  as  we  have  found  them  ;  we  confess  our 
inability  to  say  what  these  hyaline  bodies  are.  That  they  have  been  seen 
before  by  other  observers  appears  most  likely. 

We  hope  that  the  paper  will  direct  attention  to  the  subject  in  localities 
where  this  form  of  malarial  poisoning  is  more  common,  and  possibly  with 
more  material  at  command,  and  with  more  skilful  observation,  the  question 
will  be  satisfactorily  solved. 


Article  X. 

Observations  on  the  Cutaneous  and  Deep  Reflexes.    By  Philip 
Coombs  Knapp,  A.M.,  M.D.  (Harvard),  of  Boston. 

The  following  notes  upon  the  cutaneous  and  deep  reflexes  are  taken 
from  a  series  of  observations  upon  239  persons  admitted  to  the  Nervous 
and  Renal  Service  at  the  Boston  City  Hospital,  during  the  latter  half  of 
the  year  1883.  The  points  noted  were  the  presence  or  absence  of  the 
different  reflexes  in  each  patient,  a  comparison  of  the  reflexes  upon  the 
two  sides,  and  a  rough  estimate  of  the  degree  of  contraction  after  the 
irritation.  All  the  reflexes  were  tested  upon  the  bare  skin,  some  sharp- 
pointed  instrument — either  an  gesthesiometer  or  the  point  of  a  pen-knife 
— being  used  for  the  cutaneous  reflexes,  and  a  rubber-headed  percussion 
hammer  for  the  deep  reflexes. 

The  cutaneous  reflexes  examined  were  the  plantar,  cremaster,  gluteal, 
abdominal,  epigastric,  erector  spinae,  and  scapular.1  Of  these,  the  plantar 
reflex  was  the  most  constant.  In  234  cases  it  was  absent  in  17,  10  of 
which  had  some  direct  lesion  of  the  reflex  arc,  either  of  the  peripheral 
nerves  or  of  the  lumbar  cord,  six  having  multiple  neuritis,  two  myelitis 
affecting  the  lumbar  cord,  and  two  locomotor  ataxia.  Of  the  remaining 
seven  cases,  three  were  comatose,  two  from  alcohol,  and  one  from  chronic 
meningitis.    The  other  four  will  be  briefly  described  as  follows  : — 

Case  I  Michael  M.,  49  ;  alcohol  to  excess  ;  no  definite  symptoms  to 

be  obtained  ;  much  mental  impairment ;  general  pains  and  questionable 
girdle  sensation  ;  no  evidence  of  paralysis.  In  a  short  time  became  com- 
atose and  died. 

Case  II  Peter  M.,  58  ;  attacks  of  vertigo  ;  later,  left  hemiplegia  with 

contracture ;  marked  mental  impairment.  In  a  few  weeks  became  gradu- 
ually  comatose  and  died.    Tumor  in  corpus  callosum. 

1  A  description  of  these  reflexes  and  the  method  of  testing  them  may  be  found  in 
W.  R.  Gowers'  Diagnosis  of  Diseases  of  the  Spinal  Cord,  ed.  1884,  pp.  17, 18. 
No.  CLXXVIII  April,  1885.  28 


430 


Knap 


p,  Observations  on  Cutaneous  and  Deep  Reflexes.  [April 


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1885.]    Knapp,  Observations  on  Cutaneous  and  Deep  Reflexes.  431 

Case  III.— John  R.,  39 ;  alcohol  to  excess  and  exposure  to  sun. 
Headache,  vertigo,  tremor,  loss  of  appetite,  insomnia. 

Case  IV  Sarah  M.,  49  ;  vomiting,  headache,  slight  oedema  of  feet 

before  entrance.  Excited,  noisy,  and  incoherent ;  refused  food  ;  delusions 
of  poisoning.  Urine,  trace  of  albumen,  hyaline  and  granular  casts. 
(See  Table  I.) 

In  these  seven  cases,  -then,  there  is  no  clear  evidence  of  a  lesion 
which  might  act  as  a  direct  break  in  the  path  of  the  transmission  of  the 
nerve  currents,  but  there  is  evidence  of  disturbance  of  the  higher  nerve 
centres.  It  is  a  well-known  fact  that  a  lesion  in  one  cerebral  hemi- 
sphere, as  a  hemorrhage,  causing  hemiplegia  on  the  opposite  side  of  the 
body,  may,  at  least  temporarily,  diminish  or  abolish  the  cutaneous  re- 
flexes on  the  paralyzed  side,  showing  that  the  cerebral  disturbance  has  a 
direct  inhibitory  influence.  This  seems  a  satisfactory  explanation  of  the 
absence  of  the  reflex  in  the  first  five  cases ;  in  the  last  two  the  disturb- 
ance seems  hardly  severe  enough  to  have  much  inhibitory  action,  yet 
such  an  explanation  is  not  impossible,  and  is  the  only  one  I  can  suggest. 
In  no  case,  at  all  events,  was  it  absent  where  there  was  not  some  well- 
marked  disturbance  of  the  nervous  system,  either  a  direct  lesion  of  the 
reflex  arc  or  some  cerebral  disorder. 

The  cremaster  was  second  in  constancy  among  the  cutaneous  reflexes. 
In  21  cases  out  of  167  it  was  absent,  and  in  two  cases  the  cause  of  its 
absence  was  local — extreme  oedema  of  the  scrotum,  and  double  hernia 
with  hydrocele.  Eight  of  the  other  19  cases  had  the  plantar  reflex  also 
absent — two  cases  of  multiple  neuritis,  one  of  locomotor  ataxia,  one  of 
acute  myelitis,  one  of  tumor  of  the  brain  (Case  II.),  two  of  coma,  and 
one  of  obscure  cerebral  disease  (Case  I.).  Of  the  other  eleven,  one  had 
multiple  neuritis,  one  chronic  myelitis,  a  third  meningitis  with  obscure 
spinal  symptoms  and  paraparesis,  a  fourth,  with  a  history  of  convulsions, 
had  clonic  spasms  and  loss  of  power  in  one  leg,  with  some  tenderness 
along  the  nerve  trunks,  the  fifth  was  a  recent  hemiplegia,  the  sixth  was 
an  alcoholic  case,  delirious,  with  occasional  convulsions  later,  who  had 
chronic  interstitial  hepatitis  and  nephritis,  one  had  uraemic  convulsions, 
three  were  comatose  (two  from  uraemia  and  one  from  alcohol),  and  the 
last,  an  alcoholic  subject,  had  acute  pneumonia  with  slight  delirium. 
(See  Table  II.) 

These  cases,  then,  with  a  single  exception,  show  either  a  direct  lesion 
of  the  reflex  arc,  or  severe  disturbance  of  the  higher  nerve  centres  which 
might  inhibit  the  reflex,  even  more  clearly  than  the  cases  where  the 
plantar  reflex  was  absent.  The  delirium  in  the  case  of  pneumonia  was 
slight,  and  does  not  seem  sufficient  to  explain  the  absence  of  the  cremas- 
ter reflex  in  that  case,  yet  it  was  the  only  nervous  disturbance  to 
account  for  it. 

Following  the  analogy  of  those  cases  of  hemiplegia  which  show  the 
cutaneous  reflexes  absent  on  the  paralyzed  side,  the  absence  of  the 


432 


Knapp,  Observations  on  Cutaneous  and  Deep  Reflexes.  [April 


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1885.]    Knapp,  Observations  on  Cutaneous  and  Deep  Reflexes.  433 

plantar  and  cremaster  reflexes  in  so 'many  cases  of  cerebral  disease  of  one 
sort  or  another,  where  the  cord  and  peripheral  nerves  were  intact,  gives 
additional  support  to  the  hypothesis  that  an  irritative  lesion  in  the  brain, 
exciting  the  inhibitory  centres  in  the  basal  ganglia  and  the  motor  fibres 
in  the  pyramidal  tract,  may  inhibit  the  action  of  the  cells  in  the  gray 
matter  in  the  cord,  and  so  abolish  reflex  action. 

Although  the  absence  of  these  reflexes  may  be  thus  explained,  the 
observations  do  not  permit  the  opposite  course  of  reasoning,  that,  having 
a  lesion  in  the  cord  or  peripheral  nerves,  or  an  irritative  lesion  in  the 
brain,  these  reflexes  must  be  absent.  Their  persistence  in  locomotor 
ataxia  has  long  been  noticed,  and  has  been  explained  by  Bramwell  by  the 
theory  that  nerve-fibres  conducting  sensations  from  the  skin  pass  directly 
into  the  posterior  cornua,  while  fibres  from  the  deeper  parts,  like  the  ten- 
dons, pass  through  the  posterior  root  zones.1  The  plantar  reflex  was 
present  in  six  out  of  eight  cases  of  locomotor  ataxia,  the  cremaster  in 
seven,  the  eighth  case  being  a  woman.  The  plantar  reflex  was  seen  in 
two  cases  of  coma  where  the  cremaster  was  absent,  and  in  nine  out  of 
fourteen  cases  of  multiple  neuritis  ;  the  cremaster  was  seen  in  five  cases 
out  of  eight  of  the  same  disease.  Their  presence,  therefore,  does  not 
enable  one  to  exclude  such  diseases,  but  their  absence  usually,  if  not 
always,  implies  some  nervous  disturbance. 

The  other  cutaneous  reflexes  appeared  to  be  of  much  less  value.  The 
gluteal  reflex  was  third  in  constancy,  but  in  179  cases  it  was  absent  in 
66,  and  these  differed  so  much  as  to  render  deductions  from  its  absence 
of  very  little  worth.  Many  of  the  cases,  from  the  class  of  diseases  ad- 
mitted to  the  service,  had  some  nervous  trouble,  but  its  absence  was  seen, 
not  only  in  hemiplegia,  locomotor  ataxia,  and  multiple  neuritis,  but  also  in 
various  neuralgias  and  the  localized  paralyses  of  the  upper  extremity 
from  injury  of  the  circumflex  or  musculo-spiral  nerve,  and  even  in  cases 
of  renal  or  cardiac  disease  and  phthisis,  so  that  it  would  be  unsafe  to 
make  any  assertions  as  to  the  cause  of  its  absence. 

The  same  thing  may  be  said  of  the  abdominal  reflex,  which  was  absent 
in  97  cases  out  of  239,  cases  of  as  varied  sorts  as  those  just  mentioned. 

The  result  of  testing  the  epigastric  reflex,  which  Gowers  claims  is  sin- 
gularly uniform,  was  still  more  unsatisfactory,  for  it  was  absent  in  more 
than  half  the  cases,  namely,  in  142  out  of  239.  . 

The  cutaneous  reflexes  of  the  back,  the  erector  spinae,  and  the  scapular 
were  of  such  rare  occurrence  that  the  question  naturally  rose  whether 
their  presence  might 'not  be  pathological.  The  erector  spinas  reflex  was 
present  in  45  cases  out  of  178,  but  among  these  cases,  besides  various 
nervous  diseases,  were  acute  nephritis,  hsematemesis,  acute  rheumatism, 
debility,  and  pneumonia.  The  scapular  reflex  was  present  but  15  times 
in  177  cases,  and  these  15  cases  again  varied  so  much  that  no  inferences 

1  B.  Bramwell,  Diseases  of  the  Spinal  Cord,  ed.  1882,  p.  Ill,  note. 


434      Knapp,  Observations  on  Cutaneous  and  Deep  Reflexes.  [April 

could  be  drawn  from  its  presence.  One  point  of  some  interest,  however, 
was  noted  in  regard  to  those  reflexes,  namely,  some  relation  between  their 
presence  and  that  of  the  corresponding  deep  reflexes.  In  33  cases  out  of 
178  the  reflex  from  the  lumbar  fascia  was  present;  in  17  of  these  cases 
the  erector  spinae  reflex  was  also  found.  In  45  cases  out  of  178  there  was 
a  reflex  from  the  spine  of  the  scapula,  and  in  ten  of  these  the  scapular 
cutaneous  reflex  was  present. 

The  observations  upon  the  increase  or  diminution  of  the  cutaneous  re- 
flexes seemed  to  indicate  that  such  a  variation  was  of  only  moderate 
value  in  diagnosis.  Such  tests  as  are  employed  at  the  bedside  are  neces- 
sarily rough,  and  the  normal  standard  is  only  an  approximate  one  which 
varies  with  each  observer,  and  variations  from  this  standard  cannot  be 
measured  with  any  accuracy.  Again,  the  reflex  may  vary  in  intensity  in 
healthy  individuals,  a  slight  plantar  reflex  being  no  more  pathological 
than  a  slight  patellar  reflex,  and  the  intensity  is  modified  by  several  con- 
ditions, like  thickness  of  the  plantar  epidermis,  natural  susceptibility  to 
tickling,  and  even  expectant  attention.  I  have  repeatedly  seen  an  unex- 
pected prick  of  the  sole  of  the  foot  followed  by  a  vigorous  contraction  of 
the  whole  leg,  while  subsequent  pricks  gave  merely  a  moderate  drawing 
up  of  the  leg  or  only  a  contraction  of  the  toes.  A  diminution  of  the 
reflexes  is  a  thing  to  be  expected  in  neuritis,  in  myelitis,  or  in  hemi- 
plegia, and  often  gives  useful  information,  but  an  equal  feebleness  of  con- 
traction may  be  seen  in  nephritis,  dyspepsia,  valvular  disease  of  the 
heart,  lumbago,  anaemia,  phthisis,  and  pleurisy,  so  that  its  value  depends 
upon  its  relation  to  other  symptoms.  Increase  of  the  cutaneous  reflexes, 
too,  has  not  the  significance  of  increase  of  the  deep  reflexes,  for  it  was 
noted  in  cases  of  paraplegia  and  neuritis  where  the  patellar  reflex  was 
absent,  as  well  as  in  myelitis  and  multiple  sclerosis,  involving  the  lateral 
columns,  where  the  deep  reflexes  were  exaggerated,  and  also  in  cases 
where  there  was  no  nervous  trouble  at  all,  as  in  phthisis,  nephritis,  hepa- 
titis, and  in  health.  As  an  isolated  symptom  neither  diminution  nor  increase 
of  the  cutaneous  reflexes  has  any  significance,  but  with  other  symptoms, 
and  especially  by  comparing  the  different  reflexes  with  each  other,  it 
often  gives  much  information. 

If  the  reflexes  differ  on  the  two  sides,  however,  their  value  in  diag- 
nosis is  much  greater.  The  plantar  reflex  differed  in  ten  cases,  four  of 
which  had  hemiplegia,  one  hemianesthesia,  and  one  unilateral  epilepsy, 
the  reflex  being  present  on  the  convulsed  side  and  absent  on  the  other. 
In  a  case  of  uraemic  convulsions  the  reflex  was  absent  on  one  side,  but 
the  convulsions  were  general.  It  was  diminished  on  one  side  in  a  case 
of  reflex  paraplegia  following  cystitis,  and  in  another  obscure  case  of 
paraplegia,  while  a  similar  difference  was  noted  in  a  case  of  melancholia 
with  excitement,  where  the  patient's  restlessness  rendered  the  examination 
somewhat  untrustworthy. 

The  cremaster  reflex  differed  in  but  two  cases,  one  the  case  of  uni- 


1885.]    Knapp,  Observations  on  Cutaneous  and  Deep  Reflexes.  435 


lateral  epilepsy  just  mentioned,  the  other  an  obscure  case  of  spinal 
disease,  probably  an  irregular  form  of  locomotor  ataxia. 

The  gluteal  differed  in  three  cases  of  hemiplegia,  the  case  of  unilateral 
epilepsy,  and  a  case  of  chronic  myelitis,  where  the  deep  reflexes  were 
exaggerated  on  the  side  where  the  gluteal  was  present. 

The  cases  in  which  the  abdominal  and  epigastric  differed  were  not  all 
so  clearly  cases  where  a  unilateral  affection  could  be  made  out.  The 
abdominal  reflex  differed  in  seven  cases  :  one,  hemiplegia,  the  second,  an 
irregular  case  of  locomotor  ataxia,  the  third,  unilateral  epilepsy,  the 
fourth,  left  hemiparesis  following  a  fall  on  the  head,  where  the  abdominal 
and  epigastric  reflexes  were  absent  on  the  paretic  side,  the  fifth,  cerebral 
syphilis,  with  these  reflexes  increased  on  one  side  and  the  deep  reflexes 
on  the  other,  the  sixth,  dementia  with  lead  found  in  the  urine,  and  the 
seventh,  chronic  parenchymatous  nephritis. 

The  epigastric  reflex  differed  in  five  cases,  three  of  which  have  just 
been  mentioned,  hemiparesis,  cerebral  syphilis,  and  dementia ;  the  fourth 
had  hemiplegia ;  the  fifth  had  epilepsy,  and  was  examined  after  the  con- 
vulsion was  over. 

The  erector  spina?  reflex  differed  in  two  cases,  multiple  sclerosis  and 
hemiplegia. 

The  scapular  reflex  differed  in  three,  two  hemiplegias  and  the  case  of 
multiple  sclerosis,  which  had  marked  unilateral  symptoms. 

In  nearly  every  case,  therefore,  there  was  evidence  of  disease  of  the 
brain  or  cord,  either  unilateral  or  more  marked  upon  one  side,  the  chief 
exceptions  being  in  the  cases  where  the  abdominal  and  epigastric  reflexes 
differed.  In  one  or  two  cases,  notably  the  case  of  nephritis,  careful  ex- 
amination could  not  discover  a  reason  for  the  difference ;  hence  I  am 
not  prepared  to  assert  that  such  a  difference  is  always  pathological,  but  I 
believe  that  it  is  usually  a  sign  of  some  unilateral  disturbance  of  the 
nervous  system,  and  that  it  always  demands  careful  investigation.  (See 
Table  III.) 

Of  much  greater  interest  are  the  contractions  obtained  by  percussion  of 
tendons,  periosteum,  and  fasciae — the  deep  reflexes.  Of  these,  the  follow- 
ing were  tested :  the  reflexes  from  the  patellar  and  triceps  tendons  and 
the  extensor  tendons  of  the  wrist,  and  the  clonuses  of  the  ankle,  wrist,  and 
toe  ;  the  periosteal  reflexes  from  the  tibia,  radius,  ulna,  third  costal  car- 
tilage, and  spine  of  the  scapula  ;  and  the  reflex  from  the  lumbar  fascia. 
In  a  few  cases  where  the  other  tendon  reflexes  were  exaggerated  the 
patellar  clonus  and  the  front  tap  contraction  were  tested.1 

In  all  examinations  of  the  deep  reflexes  that  from  the  patellar  tendon 
from  its  constancy  in  health,  its  value  in  diagnosis,  and  the  study  which 
has  been  made  of  it,  is  of  the  first  interest.  In  47  cases  out  of  239  this 
reflex  was  absent  on  both  sides.    It  is  admitted  that  in  lesions  of  the 

1  For  a  full  discussion  of  these  reflexes,  see  J.  Ross,  Diseases  of  the  Nervous  Sys 
tern,  .ed.  1882,  vol.  i.  pp.  140-151,  and  W.  R.  Gowers,  op.  cit.,  pp.  19-34. 


436      Knapp,  Observations  on  Cutaneous  and  Deep  Reflexes.  [April 


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1885.]    Kxapp,  Observations  on  Cutaneous  and  Deep  Reflexes.  439 


reflex  arc,  as  in  neuritis,  meningitis  involving  the  nerve-roots,  locomotor 
ataxia,  myelitis,  anterior  poliomyelitis,  progressive  muscular  atrophy,  and 
pseudo-hypertrophic  muscular  paralysis,  the  patellar  reflex  may  be  absent. 
Hence  thirteen  cases  of  multiple  neuritis,  seven  cases  of  locomotor  ataxia, 
two  cases  of  myelitis,  two  cases  of  meningitis,  a  case  of  diphtheritic  para- 
plegia, and  three  cases  of  paraplegia,  or  paraparesis  of  obscure  spinal 
origin,  in  all  of  which  the  patellar  reflex  was  absent,  may  be  dismissed 
without  further  comment.  In  very  stout  people  with  short  tendons  West- 
phal  states1  that  it  is  very  difficult  to  get  the  reflex ;  the  difficulty  is 
increased  if  the  legs  are  oedematous.  This  may  account  for  the  failure  to 
obtain  it  in  three  very  stout  women.  Four  more  were  cases  of  coma,  one 
from  uraemia,  three  from  alcohol ;  in  one  of  these  the  reflex  was  well 
marked  on  recovery  the  next  day ;  the  others  were  not  tested.  The 
remaining  twelve  will  be  briefly  described  : — 

Case  I  John  F.,  48.    Intercostal  neuralgia,  probably  malarial.  Hole 

in  skull,  from  bullet  wound,  over  second  frontal  convolution,  right.  At 
times  convulsive  movements  of  right  arm,  vertigo,  loss  of  consciousness. 

Case  II  Michael  M.,  49.  Alcohol  to  excess.  No  definite  symp- 
toms to  be  obtained ;  much  mental  impairment ;  general  pains  and  ques- 
tionable girdle  sensation ;  no  evidence  of  paralysis.  In  a  short  time 
became  comatose  and  died.    [Case  I.  under  plantar  reflex.] 

Case  III — Edward  R.,  44.  Alcohol  to  excess.  Nervous,  tremulous, 
sleepless.    (Edema  of  legs.  Albuminuria. 

Case  IV — Terence  M.,  65.  Alcohol  to  excess.  Delirious  two  weeks. 
Much  mental  impairment ;  gives  no  intelligent  history  ;  complains  chiefly 
of  chest.    Ocular  paresis  ;  hallucinations  of  sight.    Later  coma  and  death. 

Case  V  Michael  M.,  30.    Alcohol  to  excess.    General  epileptiform 

convulsions.  No  oedema  ;  urine  of  acute  nephritis.  Later  delirious,  hal- 
lucinations of  vision  ;  coma  and  death.  No  reflex  in  convulsive  or  deliri- 
ous stage. 

Case  VI — D wight  S.,  35.  Alcohol  to  excess.  Delirious  and  tremu- 
lous. Occasional  epileptiform  convulsion.  Albumen,  hyaline  and  granular 
casts.    Liver  much  enlarged.    Reflex  not  tested  in  convulsion. 

Case  VII  Cornelius  F.,  32.  Disease  of  aortic  valves.  Right  hemi- 
plegia 6-7  months  before  ;  recovery.    Left  hemiplegia. 

Case  VIII — Julia  H.,  60?  Much  demented.  Question  of  old  left 
hemiplegia.    Slight  paresis  of  left  side  of  face. 

Case  IX. — Sarah  M.,  49.  Vomiting,  headache,  slight  oedema  of  feet 
before  entrance.  Excited,  noisy,  and  incoherent ;  refused  food  ;  delusions 
of  poisoning.  Trace  of  albumen,  hyaline  and  granular  casts.  [Case  IV. 
under  plantar  reflex.] 

Case  X — Jeremiah  B.,  44.  Fell  from  ladder,  striking  left  hip.  Much 
pain  about  hip.    No  evidence  of  fracture.    No  pain  down  leg. 

Case  XI — Ellen  W.,  35.  Facial  neuralgia  ;  cancer  of  breast  ;  systolic 
murmur  at  apex  of  heart.  Badly  nourished,  broken-down,  neuropathic 
subject. 

Case  XII  Michael  S.,  11.    Question  of  previous  scarlatina.  Mild 

acute  nephritis,  some  oedema.    No  nervous  symptoms.    (See  Table  IV.) 

1  C.  "Westpbal,  Ueber  das  Verscbwinden  und  die  Localisation  des  Kniepb'anomens. 
Berlin.  Kliniscb.  Wocbenscbrift,  Jan.  3,  1Q,  1881. 


440      Knapp,  Observations  on  Cutaneous  and  Deep  Reflexes.  [April 


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442      Knapp,  Observations  on  Cutaneous  and  Deep  Reflexes.  [April 

Finding  the  patellar  reflex  absent  in  every  case  of  coma  that  was  exam- 
ined, and  being  led  to  believe  that  in  one  case  at  least  its  absence  was  due 
to  the  coma,  I  naturally  was  brought  to  the  inquiry  whether  etherization 
affected  the  reflex.  The  only  statement  upon  the  point  that  I  found  was 
that  by  Horsley  that  ether  and  nitrous  oxide  do  not  diminish  it.1  I  took 
occasion  to  test  the  reflex  of  a  patient  that  I  had  etherized  to  remove  a 
chalazion — a  nervous,  anaemic  man  with  a  well-marked  reflex  before 
taking  ether — and  found  that  when  he  was  so  far  etherized  that  his  con- 
junctival reflex  was  gone  and  his  limbs  were  relaxed,  the  reflex  was  absent. 
Being  anxious  to  make  further  investigations,  by  the  kindness  of  Dr.  Post 
and  the  visiting  surgeons  of  the  Boston  City  Hospital,  I  was  permitted  to 
test  the  patellar  reflex  in  a  number  of  patients  before  and  during  etheriza- 
tion. A  satisfactory  test  was  made  on  thirteen  adults  and  four  children. 
In  every  case  the  reflex  was  well  marked  before  etherization,  and  the 
second  test  was  made  when  the  conjunctival  reflex  was  lost  and  the  limbs 
were  thoroughly  relaxed.  In  one  case  there  was  a  very  slight  increase, 
in  nine  cases  there  was  no  change,  in  two  cases  it  was  somewhat  dimin- 
ished, and  in  five,  one  adult  and  all  the  children,  it  was  entirely  absent. 

Before  discussing  the  cause  of  the  absence  of  the  patellar  reflex  I  will 
speak  of  the  other  changes  found  in  it  and  of  the  other  deep  reflexes  of  the 
lower  extremity.  A  diminution  of  the  contraction,  although  often  accom- 
panying some  definite  lesion  of  the  reflex  arc,  as  in  incipient  locomotor 
ataxia  or  in  mild  cases  of  multiple  neuritis,  is  not  of  much  weight,  for  a 
very  feeble  contraction  is  not  inconsistent  with  perfect  health.  Absence 
or  marked  exaggeration  is  alone  of  significance.2 

In  eight  cases  the  patellar  reflex  was  markedly  increased,  and  in  seven 
it  proved  a  most  valuable  symptom.  Four  of  the  cases  had  myelitis,  one 
an  acute  myelitis  in  the  dorsal  region,  the  other  three  chronic  myelitis, 
probably  combined  sclerosis  of  the  posterior  and  lateral  columns  ;  one  was 
a  case  of  multiple  sclerosis  involving  the  lateral  columns  ;  one  a  case  of 
secondary  degeneration  of  the  lateral  columns  following  a  tumor  of  the 
pons  ;  once  it  was  noted  after  the  convulsions  in  unilateral  epilepsy  ;  and 
once  it  was  seen  in  a  case  of  alcoholism,  with  an  obscure  history  of  convul- 
sions, not  examined  until  some  hours  after  admission,  and  under  observa- 
tion a  very  short  time — a  case  where  all  the  tendon  reflexes  were 
exaggerated,  but  for  which  no  cause  could  be  assigned  in  the  short  time  it 
could  be  observed. 

In  cases  where  the  reflex  was  thus  markedly  exaggerated  an  attempt 
was  made  to  get  the  patellar  clonus,  which  was  found  in  five  cases.  Four 
of  these  had  disease  of  the  lateral  columns,  two  combined  sclerosis,  one 
multiple  sclerosis,  and  one  secondary  degeneration;  the  fifth  had  acute 

1  Quoted  by  W.  R.  Gowers,  op.  cit.,  p.  31. 

2  J.  M.  Charcot,  Localization  of  Cerebral  and  Spinal  Diseases  [Syd.  Soc's  trans- 
lation], 1883,  p.  25. 


1885.]   *Knapp,  Observations  on  Cutaneous  and  Deep  Reflexes.  443 

rheumatism  with  endocarditis,  and  there  was  a  slight  and  irregular  clonus 
at  times  on  the  left  side  ;  the  patellar  reflex  and  the  deep  reflexes  of  the 
upper  extremity  were  increased  on  that  side.    (See  Table  V.) 

In  six  cases  the  patellar  reflex  was  absent  on  one  side  :  a  case  of  incipi- 
ent locomotor  ataxia,  a  mild  case  of  multiple  neuritis,  a  case  of  hemiplegia 
where  it  was  absent  on  the  paralyzed  side,  a  case  of  severe  crural  neu- 
ralgia following  a  fall  where  it  was  absent  on  the  affected  side,  a  case  of 
diabetes  mellitus  with  pain  and  prickly  feelings  in  the  legs,  and  a  case 
of  dementia  with  evidence  of  lead-poisoning.  In  nine  cases  it  was  dimin- 
ished on  one  side :  three  of  these  were  cases  of  severe  and  protracted 
sciatica  where  it  was  less  on  the  affected  side,  one  was  a  case  of  hemiplegia 
where  it  was  most  marked  on  the  paralyzed  side  (this  case  afterward 
showed  contracture  and  exaggeration  of  the  reflexes  on  that  side),  a  case 
of  cerebral  meningitis,  a  case  of  obscure  paraplegia,  a  case  of  hypochon- 
driasis, a  case  of  recent  hemiplegia  where  it  was  diminished  on  the  para- 
lyzed side,  and  a  case  of  apoplexy.  In  three  cases  it  was  increased  on  one 
side  :  a  case  of  hysterical  hemiplegia  where  it  was  most  marked  on  the 
paralyzed  side,  a  case  of  cerebral  syphilis  where  several  deep  reflexes 
were  increased  on  the  same  side,  and  a  case  of  paraparesis  from  being 
trampled  on  by  a  horse.  In  the  case  of  dementia,  where  no  history  could 
be  obtained  and  no  trustworthy  examination  could  be  made,  it  is  possible 
that  the  lead  in  the  system  may  have  affected  the  cord  or  the  peripheral 
nerves.  With  this  exception  the  difference  seems  pretty  well  accounted 
for  except  in  the  case  of  hypochondriasis.    (See  Table  III.) 

In  18  cases  out  of  231  a  reflex  was  obtained  from  the  periosteum  of  the 
tibia — a  reflex  closely  allied  to  that  from  the  patellar  tendon,  which 
Schultz  considers  an  indication  of  the  reflex  character  of  tendon  phenom- 
ena.1 In  five  cases  it  was  but  slight,  and  was  not  attended  with  any 
marked  exaggeration  of  the  patellar  reflex.  In  eleven  cases  the  patellar 
was  exaggerated,  although  not  always  to  such  a  degree  as  to  be  pathologi- 
cal, so  that  its  presence  seems  to  be  rather  of  corroborative  value  as  an 
indication  of  exaggeration  of  the  deep  reflexes  than  pathognomonic  of  dis- 
ease of  the  lateral  columns.  In  two  cases  of  hemiplegia  it  was  present  on 
the  paralyzed  side  only. 

Second  in  importance  to  the  patellar  reflex,  though  not  in  frequency, 
comes  ankle  clonus.  In  12  cases  out  of  238  it  was  found  on  one  or  both 
sides,  and  in  every  case  there  was  a  definite  pathological  cause.  In  four 
cases  it  was  seen  temporarily  after  a  convulsion,  once  in  unilateral  epi- 
lepsy, on  the  convulsed  side  only.  The  other  cases  gave  clear  evidence 
of  disease  of  the  lateral  columns  :  three  were  cases  of  combined  sclerosis 
of  the  posterior  and  lateral  columns,  one  was  a  case  of  multiple  sclerosis 

1  R.  Schultz,  Die  Bedeutung  der  Sehnenreflexe,  etc.,  Deutsches  Archiv  fur  kl. 
Medicin,  Feb.  14,  1882. 


444     Knapp,  Observations  on  Cutaneous  and  Deep  Reflexes'  [April 

involving  the  lateral  columns,  one  was  an  acute  myelitis  in  the  dorsal 
region  with  probable  descending  degeneration,  one  was  a  case  of  secondary 
degeneration  following  tumor  of  the  pons,  one  a  unilateral  degeneration 
in  old  hemiplegia,  and  one  a  case  of  cerebral  syphilis  with  unilateral  exag- 
geration of  the  deep  reflexes.    (See  Table  V.) 

I  regret  to  say  that  no  regular  test  was  made  of  front  tap  contraction. 
It  was  present,  of  course,  in  the  cases  of  ankle  clonus,  and  in  the  case  of 
alcoholism  where  the  patellar  reflex  was  exaggerated.  It  was  tested  in  a 
few  other  cases  of  exaggerated  reflexes,  but  was  not  obtained.  The  wrist 
and  toe  clonuses  were  tested  in  every  case,  but  never  found. 

Returning  now  to  the  cases  in  which  the  patellar  reflex  was  absent,  it 
will  be  remembered  that  the  larger  part  of  them  had  some  lesion  of  the 
reflex  arc,  but  that  a  considerable  percentage  presented  no  evidence  of 
such  a  lesion.  The  first  nine  cases  quoted  at  some  detail  were  cases  of 
cerebral  disturbance,  usually  with  the  history  of  alcoholic  excess.  The 
tenth  case  may  have  some  spinal  disturbance  as  a  result  of  his  fall ;  the 
eleventh  was  one  of  those  patients  wrhose  nervous  system  is  wholly  worn 
out,  cases  in  which  at  times  Berger  and  Bloch  found  the  reflex  absent.1 
The  cause  of  its  absence  in  the  twelfth  case  I  cannot  determine.  Perhaps 
slight  disturbances  in  children  may  affect  the  reflex,  since  all  the  children 
examined  lost  it  under  ether,  but  that  is  a  point  which  demands  further 
investigation. 

It  has  been  admitted,  and  these  observations  help  to  confirm  the  fact, 
that  the  cutaneous  reflexes  may  be  lost  in  cases  of  disease  of  the  higher 
centres,  that  is,  of  the  brain.  If  the  knee  phenomenon  be  really  a  spinal 
reflex,  why  may  not  disease  of  the  brain  in  like  manner  diminish  or  abol- 
ish it? 

It  has  long  been  known  that  disease  of  the  pyramidal  tract  in  the  brain 
may  be  followed  by  a  descending  degeneration  of  the  lateral  columns  in 
the  cord,  one  of  the  symptoms  of  which  is  an  exaggeration  of  the  deep 
reflexes.  This  degeneration,  according  to  Schiefferdecker's  experiments 
on  dogs,  does  not  begin  until  the  fourteenth  day  at  the  earliest,2  which 
agrees  with  the  clinical  observations  that  late  contracture  in  hemiplegia 
comes  on  from  the  fifteenth  to  the  thirtieth  day,  or  even  later.  In  cases 
of  direct  hemiplegia,  as  from  a  hemorrhage  in  the  middle  third  of  the 
internal  capsule,  Charcot  asserts  that  ankle  clonus  on  the  paralyzed  side 
precedes  the  contracture,  and  that  exaggeration  of  the  deep  reflexes  pre- 
cedes ankle  clonus,  the  exaggeration  being  valuable  as  a  premonition  of 
contracture,  and  occurring,  perhaps,  before  there  is  actual  degeneration  in 
the  cord.3    In  one  case  of  hemiplegia  I  found  that  contracture  appeared 

1  Dr.  Berger,  Ueber  Sehnenreflexe,  Centralblatt  far  Nervenh.  etc.,  Feb.  15,  1879. 
See  also  R.  Schultz,  art.  cit. 

2  Quoted  by  J.  Ross,  op.  cit.,  vol.  ii.  p.  91. 

3  J.  M.  Charcot,  op.  cit.,  p.  248  et  seq. 


1885.]    Kn a pp,  Observations  on  Cutaneous  and  Deep  Reflexes.  445 


Deep  Reflexes. 

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R.  unilateral  epilepsy  [during  fits] 
Multiple    sclerosis    [left   side  most 

Tumor  of  pons  

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Cerebral  syphilis  

Name. 

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No.  CLXXVIII  April,  1885. 


29 


446      Knapp,  Observations  on  Cutaneous  and  Deep  Reflexes.  [April 

some  weeks  after  a  difference  in  the  deep  reflexes  on  the  two  sides  was 
noted  ;  a  second  case  where  a  like  difference  was  observed  was  not  under 
observation  long  enough  to  notice  whether  contracture  occurred.  That 
such  exaggeration  is  not  always  due  to  structural  changes  in  the  lateral 
columns  is  shown  by  the  occurrence  of  ankle  clonus  after  epileptiform  con- 
vulsions, which  was  first  observed  by  Hughlings  Jackson,1  and  later  by 
Gowers,  Beevor,2  and  others, — a  phenomenon  which  I  have  noticed  in  four 
cases  of  epileptic  and  epileptiform  convulsions  arising  from  various  causes. 
In  such  cases  there  can  of  course  be  no  wasting  of  nerve-fibres  as  in 
sclerosis,  and  Jackson  explains  the  phenomenon  by  the  hypothesis  of  an 
exhaustion  of  the  nerve-fibres  in  the  lateral  columns,  thereby  perhaps 
causing  a  loss  of  control  by  the  cerebrum,  the  cerebellar  influence  being 
unantagonized,  or,  what  he  thinks  even  more  probable,  there  being  also 
an  exhaustion  of  inhibitory  centres  in  the  cord  itself.3  When  this  exhaus- 
tion extends  down  so  far  as  to  affect  the  cells  in  the  lumbar  centres, 
instead  of  an  increase  of  the  reflex,  it  may  be  lost  entirely,  as  has  been 
noticed  by  Westphal4  and  Gowers,5  the  latter  of  whom  suggests  this  theory 
as  an  explanation.  This  will  account  for  the  absence  of  the  reflex  in 
Case  V. 

If  new  disturbances  in  the  brain  which  either  cut  off  the  cerebral  in- 
fluence by  a  direct  lesion,  as  in  hemiplegia,  or  by  an  exhaustion  of  the 
conducting  fibres,  as  in  convulsions,  increase  the  reflex,  why  may  not  an 
irritative  lesion  of  the  motor  tract,  by  increasing  the  activity  of  the  fibres 
in  the  lateral  columns,  inhibit  it  ?  That  the  lateral  columns  are  excit- 
able, though  to  a  less  degree  than  nerves,  has  been  demonstrated  by 
various  observers.6  Moreover,  the  patellar  reflex  has  been  occasionally 
found  absent  by  Westphal  on  the  paralyzed  side  in  hemiplegia.7  Why 
may  not  the  absence  of  the  reflex  then,  in  the  cases  of  cerebral  disturb- 
ance which  I  have  quoted,  be  due  to  the  over-activity  of  the  lateral 
columns  from  some  general  irritation  in  the  brain?  In  most  of  them 
spinal  symptoms  were  absent,  and  the  cerebral  disturbance  was  the  only 
discoverable  cause  of  the  absence  of  the  reflex.  The  abuse  of  alcohol 
may  have  been  a  further  factor  in  the  causation,  but  more  observations 
on  similar  cases  must  be  made  before  the  point  can  be  determined.  The 
theory,  at  any  rate,  seems  plausible,  as  a  means  of  explaining  the  absence 
of  the  reflex. 

In  further  support  of  this  hypothesis  I  will  mention  one  case  a  little 

1  J.  Hughlings  Jackson,  On  a  case  of  temporary  left  hemiplegia,  with  foot-clonus 
and  exaggerated  knee- phenomenon,  after  an  epileptiform  seizure.  Medical  Times  and 
Gazette,  Feb.  12, 1881. 

2  W.  R.  Gowers,  On  Epilepsy,  etc.,  ed.  1881,  p.  100. 

3  J.  Hughlings  Jackson,  Croonian  Lectures  on  the  Evolution  and  Dissolution  of 
the  Nervous  System.    Lancet,  April  12, 1884. 

4  C.  Westphal,  art.  cit.  5  W.  R.  Gowers,  On  Epilepsy,  p.  101. 
6  J.  M.  Charcot,  op.  cit.,  p.  235.                7  C.  Westphal,  art.  cit. 


1885.]    Knapp,  Observations  on  Cutaneous  and  Deep  Reflexes.  447 

more  fully.  A  man  was  attacked  with  sudden  paraplegia  after  excessive 
coitus,  and  a  diagnosis  of  acute  myelitis  was  made,  which  was  localized 
in  the  lower  dorsal  and  the  lumbar  regions.  Two  or  three  days  later, 
when  he  entered  the  hospital,  the  skin  reflexes  below  the  epigastric  were 
absent,  and  there  was  no  patellar  reflex.  I  did  not  see  the  case  in  its 
later  stages,  but  Dr.  Robert  Bell,  the  house  physician  at  the  time,  told  me 
that  six  or  eight  weeks  later  he  had  exaggerated  patellar  reflex,  ankle 
clonus,  and  much  rigidity  and  muscular  spasm  in  the  legs.  Supposing 
that  the  upper  lumbar  region  with  the  dorsal  was  the  part  diseased,  the 
irritation  of  the  lateral  columns  in  the  lower  lumbar  region  from  the 
acute  process  may  have  served  to  inhibit  the  reflex  at  the  first,  but,  after 
descending  degeneration  had  begun,  the  influences  from  above  may  have 
been  checked  in  their  transmission,  the  inhibition  may  thus  have  been  cut 
off,  and  the  symptoms  of  a  lateral  sclerosis  have  arisen. 

This  does  not,  however,  seem  a  satisfactory  explanation  of  the  absence 
of  patellar  reflex  in  the  cases  of  coma.  This  I  believe  to  be  due  to  a 
paralysis  of  the  reflex  centre  in  the  cord.  Alcohol  and  probably  ether, 
and  perhaps  the  poison  in  uraemia,  paralyze  the  least  organized,  the  most 
complex,  the  least  automatic,  the  least  perfectly  reflex  centres  first — if  they 
did  not,  as  Jackson  says,  "  death  from  alcohol  would  be  a  very  common 
thing  "* — hence,  in  profound  alcoholism  it  is  not  strange  if  the  centre  for 
the  knee  phenomenon  is  paralyzed  before  the  most  perfectly  reflex  centres, 
those  of  the  respiration  and  the  circulation. 

As  regards  the  deep  reflexes  of  the  upper  extremity  Bramwell  asserts 
that  they  are  seldom,  if  ever,  present  in  health,2  and  Ross  states  that  they 
are  obtained  under  circumstances  analogous  to  those  in  which  the  patellar 
reflex  is  exaggerated.3  In  the  cases  examined,  however,  some  of  these 
reflexes  were  generally  present. 

The  triceps  reflex  proved  to  be  the  most  constant  of  the  deep  reflexes, 
not  even  excepting  the  patellar  reflex,  it  being  absent  in  but  41  cases  out 
of  239.  It  was  absent  in  nine  cases  of  multiple  neuritis,  two  cases  of 
spinal  meningitis,  two  cases  of  locomotor  ataxia  where  there  was  but  little 
impairment  of  co-ordination  in  the  arms,  a  case  of  lead  paralysis,  and 
a  case  of  diphtheritic  paralysis  where  the  legs  were  chiefly  affected.  In 
22  cases  the  patellar  reflex  was  present.  The  other  cases  were  of  various 
sorts,  acute  and  chronic  nephritis,  neuralgias  in  different  parts,  valvular 
disease  of  the  heart,  debility,  alcoholism,  dyspepsia,  etc.,  so  that  its  ab- 
sence would  seem  to  be  of  no  particular  significance.  It  was  markedly 
exaggerated  in  a  case  of  acute  dorsal  myelitis,  during  a  convulsion  in 
unilateral  epilepsy,  and  in  a  case  of  descending  degeneration  of  the  cord 

1  J.  Hughlings  Jackson,  Croonian  Lectures  on  the  Evolution  and  Dissolution  of  the 
Nervous  System.    Lancet,  March  29,  1884. 

2  B.  Bramwell,  op.  cit.,  p.  117.  3  J.  Ross,  op.  cit.,  vol.  i.  p.  154. 


448      Knapp,  Observations  on  Cutaneous  and  Deep  Reflexes.  [April 


from  tumor  of  the  pons.    In  five  cases  it  differed  on  the  two  sides, in 
three  cases  of  hemiplegia  where  it  was  most  marked  on  the  paralyzed 
side,  in  a  case  of  obscure  paraparesis  of  spinal  origin,  and  in  a  case 
herpes  zoster  thoracica,  where  it  was  absent  on  the  affected  side. 

The  radial  reflex  was  present  in  131  cases  out  of  239,  the  ulnar  in 
61,  the  reflex  from  the  extensor  tendons  of  the  wrist  in  25.  They  were 
absent  in  too  many  cases  for  it  to  have  any  special  significance,  and, 
although  present  in  many  cases  of  exaggerated  patellar  reflex,  they  also 
occurred  in  cases  of  arthritis,  hsematemesis,  valvular  disease  of  the  heart, 
etc.,  where  the  nervous  system  was  apparently  healthy.  Exaggeration, 
though  seen  in  some  cases  of  disease  of  the  lateral  columns,  was  not 
noticed  in  every  case,  and  was  also  noticed  without  special  nervous  dis- 
order. 

In  twelve  cases  the  radial  reflex  differed  on  the  two  sides,  in  eleven  of 
which  there  was  disease  of  the  brain,  cord,  or  peripheral  nerves,  clearly 
or  probably  more  marked  on  one  side  than  on  the  other.  In  a  case  of 
marked  anaemia  both  the  radial  and  ulnar  reflexes  were  present  to  a  slight 
degree  on  one  side  only.  In  six  other  cases  where  the  ulnar  differed 
there  was  disease  of  the  brain  or  cord  most  pronounced  on  one  side.  The 
reflex  from  the  extensor  tendons  differed  in  a  case  of  hemiplegia,  and  of 
dorsal  myelitis ;  it  was  also  absent  on  one  side  in  a  case  of  chronic 
nephritis,  without  nervous  symptoms,  The  wrist  clonus  was  never 
found. 

The  deep  reflexes  from  the  lumbar  fascia  and  the  spine  of  the  scapula 
are  of  rare  occurrence  and  of  insignificant  value.  The  reflex  from  the 
spine  of  the  scapula  occurred  45  times  in  178  cases,  that  from  the  lumbar 
fascia  33  times.  A  case  of  unilateral  epilepsy  was  the  only  one  in  which 
they  differed. 

The  last  reflex  on  the  list,  that  from  the  third  costal  cartilage,  has  been 
observed  more  especially  in  phthisis.  When  the  chest  is  very  fat  or 
(Edematous  it  is,  of  course,  obscured,  but  it  was  found  in  161  cases  out 
of  234.  In  ten  cases  where  it  was  increased,  six  were  cases  of  general 
exaggeration  of  the  deep  reflexes,  and  four  were  cases  of  phthisis.  But 
nine  cases  of  phthisis  were  examined,  in  those  it  was  exaggerated  in 
four,  of  which  three  were  advanced  and  one  incipient ;  it  was  normal  in 
four,  of  which  two  were  advanced,  and  it  was  absent  in  one,  which  was 
complicated  with  acute  nephritis  and  gangrene  of  the  lung.  From  so 
small  a  number  of  cases  of  phthisis  no  deductions  can  be  made,  yet  I  am 
disposed  to  believe  that  the  contraction  of  the  pectoral  from  percussion  of 
the  muscle  itself — the  muscle,  perhaps,  being  in  a  more  irritable  condition 
in  phthisis — has  been  confused  with  the  true  reflex  from  percussion  over 
the  third  costal  cartilage.  The  costal  reflex  differed  on  the  two  sides  in 
six  cases,  all  of  unilateral  cerebral  disease,  tumor,  hemiplegia,  meningitis, 
and  epilepsy. 


1885.]    Knapp,  Observations  on  Cutaneous  and  Deep  Reflexes.  449 


The  following  tables  will  show  the  frequency  of  absence  of  the  various 
reflexes : — 

Cutaneous  Reflexes. 


Cases 

Cases 

exam'ed. 

Present. 

Absent. 

exam'ed. 

Present. 

Absent. 

Plantar   .  . 

234 

217 

17 

Epigastric  .    .  . 

239 

97 

142 

Crernaster  . 

167 

146 

21 

Erector  spina?  . 

178 

45 

133 

Gluteal    .  . 

179 

113 

66 

Scapular    .    .  . 

177 

15 

162 

Abdominal  . 

239 

142 

97 

Deep  Reflexes. 

Cases 

Cases 

exam'ed. 

Present. 

Absent. 

exam'ed. 

Present. 

Absent. 

Patellar  .  . 

239 

192 

47 

Ulnar  .... 

239 

61 

178 

Tibial .    .  . 

231 

IS 

213 

Extensors  of  wrist 

239 

25 

214 

Ankle  clonus 

238 

12 

226 

Wrist  clonus  .  . 

239 

0 

239 

Toe  clonus  . 

239 

0 

239 

Costal  .... 

234 

161 

73 

Triceps    .  . 

239 

198 

41 

Lumbar  fascia 

178 

33 

145 

Radial     .  . 

239 

131 

108 

Spine  of  scapula  . 

178 

45 

133 

From  these  observations,  then,  the  following  conclusions  may  be 
drawn  : — 

L  Absence  of  the  plantar  or  cremaster  reflex  is  usually  pathological, 
depending  upon  a  direct  lesion  of  the  reflex  arc  or  some  cerebral  disturb- 
ance. 

2.  Absence  of  the  other  cutaneous  reflexes  is  not  necessarily  patho- 
logical. 

8.  Absence  of  the  patellar  reflex  may  be  due  to  cerebral  disturbance, 
especially  in  alcoholic  subjects. 

4.  Ankle  and  patellar  clonus  are  pathological. 

5.  The  deep  reflexes  of  the  upper  extremity  are  of  frequent  occur- 
rence, and  have  no  special  pathological  significance. 

6.  The  costal  reflex  is  found  in  the  majority  of  cases  without  general 
exaggeration  of  the  reflexes,  and  with  no  signs  of  phthisis,  incipient  or 
advanced. 

7.  When  the  reflexes  differ  on  the  two  sides,  though  it  usually  signifies 
some  unilateral  disease  of  the  nervous  system,  it  is  not  always  patho- 
logical. 

Finally,  these  observations  have  led  me  to  emphasize  the  value  of 
testing  all  the  reflexes,  cutaneous  and  deep,  in  the  upper  extremity  as 
well  as  in  the  lower,  and  on  the  two  sides  of  the  body,  in  examining  pa- 
tients with  nervous  diseases. 


450 


Jacobi,  Catalepsy. 


[April 


Article  XI. 

Catalepsy  in  a  Child  three  years  old.  By  A.  Jacobi,  M.D.,  Clinical 
Professor  of  Diseases  of  Children  in  the  College  of  Physicians  and  Surgeons 
of  New  York. 

Fannie  C,  aged  three  years  ;  admitted  to  Mount  Sinai  Hospital,  New 
York,  September  4,  1879.  Some  weeks  previous  to  her  admission  she 
suffered  from  headache,  for  which  she  was  given  castor  oil.  Diarrhoea 
then  set  in,  and  continued;  at  her  admission  her  pulse  was  136,  respira- 
tion 30,  and  temperature  103J°  F.  The  tongue  was  red  at  its  edges  ;  the 
spleen  was  enlarged  ;  she  had  roseola,  very  slightly  tympanites,  and  diar- 
rhoea. These  symptoms  of  her  typhoid  fever  continued  for  some  time, 
with  a  temperature  ranging  from  105°  down  to  101°  F.  She  coughed  a 
good  deal. 

September  10th.  It  was  recognized  that  she  had  whooping-cough,  and 
she  was  removed  from  the  ward. 

16th.  It  was  noted  that  the  diarrhoea  was  better,  and  on  the  17th  she 
was  without  fever.  On  the  23d  her  pulse  was  stronger,  and  it  was  hoped 
that  she  would  then  go  on  to  recovery.  On  that  day,  however,  a  slight 
spasm  of  the  eyelids  was  noticed.  She  coughed  but  little,  but  cried  a  great 
deal.  There  were  rales  with  slight  dulness  at  the  right  apex.  At  5  P.  M. 
she  urinated  quite  freely,  the  twitching  continued,  and  her  pulse  was  102 
and  weak.  She  spoke  only  a  little,  but  cried  a  good  deal  during  the  next 
few  days. 

24th.  She  had  passages  which  contained  some  undigested  milk.  Her 
appetite  was  good,  and  she  took  milk,  soup,  egg,  etc. 

^oth.  At  10  A.  M.  there  was  a  good  deal  of  twitching  of  the  lids,  and 
also  the  eyeballs  turned  upward,  tonically;  occasionally  there  was  diver- 
gent strabismus  ;  but  in  the  night  she  slept  with  her  eyes  closed. 

When  the  arms  were  lifted  up  they  would  remain  in  any  position  in 
which  they  were  placed.  When  she  was  directed,  in  a  loud  voice,  to  drop 
the  arms  she  would  slowly  do  so.  Her  legs  were  in  a  similar  condition, 
and  would  remain  in  the  position  in  which  they  were  placed.  The  fourth 
finger,  taken  separately,  remained  extended  or  flexed  when  placed  in  either 
position.  The  arm  could  be  partly  extended,  partly  flexed  with  some 
force,  and  remained  in  that  position.  Still  there  was  some  voluntary 
action  left ;  for,  when  her  arms  and  hands  were  in  a  natural  position,  she 
would  attempt  to  take  a  penny  from  the  bedclothes.  Her  muscular  action 
in  general  was  very  deficient.  When  she  was  set  up  in  bed,  her  head  fell 
forward,  and  then,  again,  when  the  arm  was  lifted  vertically,  it  would 
remain  in  that  position  for  minutes,  and  then  slowly  come  down.  During 
the  last  three  days  she  passed  a  large  quantity  of  urine,  with  a  specific 
gravity  of  1020.  Her  extremities  were  very  cold,  and  she  was  indifferent 
to  everything  about  her  ;  but  when  she  was  aroused  by  strong  impressions, 
even  the  twitchings  of  the  eyelids  would,  for  a  moment,  cease. 

27^.  The  patient  was  a  little  stronger,  and  sat  up  in  bed.  She  held 
her  head  erect  while  being  fed.  The  twitching  of  her  muscles  persisted. 
When  the  extremities  were  placed  forcibly  in  the  cataleptic  position,  reduc- 
tion was  attended  with  little  pain.  The  lower  extremities  were  less  ab- 
normal than  the  upper  ones.    She  could  stand  and  walk  two  or  three  steps. 


1885.] 


J ac obi,  Catalepsy. 


451 


Sensibility  to  contact,  pain,  and  temperatures  entirely  lost.  A  needle 
could  be  run  through  the  skin  without  eliciting  any  evidence  whatever 
that  it  produced  pain  ;  tickling  the  soles  of  the  feet  yielded  only  slight 
reflex  movements  ;  the  patella  tendon  reflex  was  greatly  diminished ;  her 
eyes  were  staring,  and  her  appetite  was  ravenous. 

28th.  Easily  awakened  from  sleep  ;  one  passage  from  the  bowels ;  an- 
swered questions  ;  anaesthesia  and  analgesia  persistent;  conjunctivae,  eye- 
balls, eyelashes  could  be  touched  without  giving  rise  to  twitching;  sight 
good ;  appetite  ravenous,  and  swallowing  easy.  Pennies  occasionally 
taken  from  the  bedclothes ;  bowels  more  constipated  than  they  were 
yesterday. 

29th.  Pulse  88 ;  respiration  26;  temperature  97°  F.  Less  twitching 
of  the  eyelids ;  patient  appeared  brighter,  but  anaesthesia  and  analgesia 
persisted,  and  the  arms  were  strongly  cataleptic  ;  appetite  continued  rave- 
nous ;  the  pupils  were  equal,  and  responded  to  light ;  the  urine  was  passed 
in  large  quantity,  and  had  a  specific  gravity  of  1020. 

30th.  Pulse  84  ;  respiration  30 ;  temperature  98°  F.  Two  stools ;  a 
small  ulceration  existing  upon  one  arm  began  to  extend  ;  the  patient  was 
very  cross ;  the  Schneiderian  membrane  was  very  sensitive  ;  slight  touch 
produced  sneezing. 

October  1st.  Pulse  92  ;  respiration  22  ;  temperature  99°  F.  The  cata- 
leptic position  of  arm  was  sustained  one  minute ;  there  was  no  twitching 
of  the  eyelids,  and  the  patient  . appeared  brighter  ;  anaesthesia  and  analgesia 
remain  unchanged.  When  an  arm  was  flexed  a  good  deal  of  strength 
was  required  to  extend  it.    Urinated  once  or  twice  every  hour. 

2d.  Loss  of  sensation  complete  ;  surface  of  body  and  extremities  warmer, 
quantity  of  urine  less,  and  strength  of  the  patient  increased. 

3d.  When  an  arm  was  extended  or  flexed  it  dropped  at  once.  Reflex 
movements  on  pricking  with  needles. 

4th.  Pulse  84;  temperature  99°  F.  Four  passages  from  the  bowels, 
for  which  tinct.  opii  camphorata  was  given ;  anaesthesia  and  analgesia  as 
before.    Four  more  passages. 

6th.  Cataleptic  position  held  out  one  minute.  Three  passages  from  the 
bowels,  and  opium  was  increased. 

7th.  Slept  well.  Passed  a  large  quantity  of  urine  ;  slight  reflex  move- 
ments on  tickling  and  pricking  the  feet.  The  opium  was  suspended,  and 
camphor  and  whiskey  given. 

8th.  Less  diarrhoea,  and  surface  warmer.  Ulceration  on  arm  looked 
better.  Again  Schneiderian  membrane  and  conjunctiva  gave  reflex  move- 
ments on  tickling. 

9th.  Patient  brighter ;  anaesthesia  and  analgesia  as  before ;  arm  and 
fingers  retained  cataleptic  position  forty-five  seconds ;  urine  1015  ;  no 
albumen.  Pulse  76;  respiration  18;  and  temperature  99°  F.  A  good 
deal  of  strength  was  required,  on  the  part  of  the  attendant,  to  overcome 
the  cataleptic  position  while  it  lasted. 

13th.  Pulse  regular ;  surface  warmer ;  feet  still  cold;  called  for  drink 
frequently,    Cataleptic  condition  unchanged. 

14th.  Sat  in  a  rocking-chair. 

15^.  Asked  for  chamber.  On  tickling,  no  reflex;  no  patella  reflex. 
Cataleptic  condition  persisted  to  a  slight  degree ;  no  twitching  of  the  eye- 
lids. 

After  this  time  the  general  condition  of  the  patient  improved,  and  at 
about  the  20th  of  October  the  cataleptic  symptoms  had  entirely  disap- 


452 


Robins,  Writers'  Cramp. 


[April 


peared.  She  was  stili  in  bed  November  5th,  but  sat  up  occasionally ;  her 
appetite  was  no  longer  ravenous  ;  urine  less  copious. 

The  child  recovered,  but  remained  anaemic  and  weak  longer  than  pa- 
tients recovering  from  typhoid  fever  are  liable  to  do. 

The  only  case  of  catalepsy  in  a  child  which  has  come  to  my  notice 
besides  the  one  reported  by  me  occurred  in  a  boy  of  thirteen,  who  suffered 
from  chorea  magna  during  the  space  of  two  years  before  he  died  in  an 
insane  asylum.  His  attacks  of  chorea  were  very  violent  indeed,  interrupted 
by  intervals  of  several  weeks,  in  which  both  his  convulsive  efforts  and  his 
psychopathic  condition  would  improve,  and  would  alternate  sometimes 
with  brief  attacks  of  catalepsy,  with  but  partial  consciousness,  diminished 
or  destroyed  will  power,  and  the  waxy  flexility,  all  of  which  symptoms 
were  present  in  my  other  case,  and  are  claimed  to  be  those  of  the  morbid 
condition  under  consideration. 

The  literature  of  the  subject  in  general  is  by  no  means  inconsiderable, 
but  the  cases  observed  during  childhood  are  but  few  in  number.  In  his 
paper,  published  in  Gerhart's  Handb.  d.  Kinderk.,  vol.  v.  1.  p.  186  et  seq., 
Monti  quotes  but  eleven  cases  met  with  in  children,  male  and  female  in 
about  equal  numbers,  of  from  five  to  fifteen  years,  the  average  age  being 
nine  years.  I  know  of  no  case  previously  reported  of  a  child  of  three 
years ;  in  it  all  the  symptoms,  psychic  indolence,  normal  or  abnormal 
temperature,  cold  surface,  anaesthesia,  analgesia,  flexibilitas  cerea,  and 
diminished  patellar  reflex  (the  latter  is  frequently  intact)  were  found  com- 
bined. The  increase  of  urine  during  a  good  part  of  the  catalepsy  was  a 
remarkable  feature,  such  as  is  seen  in  hysteria  of  both  adults  and  children. 
But  while  it  contained  no  sugar,  and  nothing  abnormal,  except  large  quanti- 
ties of  phosphates,  it  had  the,  in  children,  unusual  spec.  grav.  of  1015- 
1020. 


Article  XII. 

"Writers'  Cramp"  and  its  Treatment,  wriTH  the  Notes  or  Several 
Cases.  By  Eobert  Patterson  Robins,  M.D.,  Assistant  Demonstrator  of 
Clinical  Medicine  in  the  University  of  Pennsylvania . 

The  terms  writers'  cramp  and  scriveners'  palsy,  with  their  German  and 
French  synonyms  (Schreibekra?npJ\  crampe  des  ecrivains),  are  good  if 
applied  only  to  penmen,  but  as  the  over-movements  which  are  character- 
istic of  the  disease  have  been  noticed  also  in  artists,  violinists,  and 
pianists,  smiths,  milkmaids,  tailors,  and  sempstresses,  and  even  in  tele- 
graph operators,1  the  names  cannot  be  regarded  as  sufficiently  accurate  and 

1  Dr.  Poore  remarks  that  these  over  movements  have  an  analogue  in  some  cases  of 
spasmodic  wry  neck,  and  Duchenne  has  pointed  out  (De  l'Electrisation  Localisee,  3d  ed., 
p.  1021)  an  analogy  to  vision  troubles  due  to  prolonged  spasm  of  the  internal  recti. 
Dr.  C.  B.  Taylor,  of  Nottingham,  has  included  in  this  latter  class  a  form  of  nystagmus 
peculiar  to  miners. 


1885.] 


Robins,  Writers'  Cramp. 


453 


comprehensive.  German  authors  have  recognized  this,  and  have  from 
time  to  time  made  use  of  such  names  as  Schusterkrampf  and  Melker- 
krampf  and  the  like,  indicating  the  craft  to  which  the  patient  belonged, 
but  this  multiplication  of  synonyms  is  cumbersome  and  unsatisfactory,  and 
ought  only  to  be  resorted  to  as  a  matter  of  convenience  in  description. 
Various  terms  have  also  been  suggested,  embodying  theories  as  to  the 
causation  of  the  disease.  Duchenne,  for  instance,  calls  these  diseases 
functional  impotences,1  and  Dr.  Poore,  who  has  given  much  study  to  the 
subject,  proposes  the  name  Progressive  Functional  Ataxy.2  On  the  other 
hand,  Dr.  Zuradelli,  of  Pavia,  writes  of  them  as  irritable  weaknesses.3  So, 
also,  the  terms  chronic  local  fatigue  (Poore4),  spasmes  professionelles 
(Dally5),  co-ordinated  business  neuroses  (the  co-ordinatorische  Beschafti- 
gungsneurosen  of  Benedikt),  and  other  like  names  are  to  be  met  with  in  the 
different  treatises  on  the  subject.  None  of  them  is  entirely  satisfactory, 
but,  perhaps,  in  the  present  state  of  our  knowledge  of  the  disease,  that 
proposed  by  Dr.  Poore  (progressive  functional  ataxy)  may  be  regarded  as 
the  best. 

It  will  be  inferred  from  this  somewhat  formidable  array  of  names  that 
there  is  some  difference  of  opinion  as  to  the  pathology  of  the  disease. 
Two  theories  have  been  suggested  to  account  for  these  over-movements  : 
(1)  that  the  disease  is  of  centric  origin;  and  (2)  that  the  spasms  are 
caused  by  the  paralysis  of  certain  muscles,  and  the  consequent  strong  con- 
traction of  the  antagonizing  muscles.  Duchenne,  Althaus,6  and  Solly 
have  written  quite  copiously  in  support  of  the  first  theory.  Duchenne 
(lib.  cit.)  says  that  these  spasms  are  due  to  a  lesion  of  some  point  of  the 
nervous  centres,  "  because  (a)  the  disease  is  uninfluenced  by  localized 
faradization,  and  (b)  because  the  left  hand  in  cases  of  writer's  cramp  is  as 
liable  to  suffer  (should  it  be  used  for  writing)  as  was  the  right  one."  Mr. 
Solly,  in  a  very  interesting  and  thoughtful  course  of  lectures,7  gives  it  as 
his  opinion  that  the  lesion  is  to  be  found  in  the  spinal  cord,  and  that  the 
disease  consists  of  a  granular  disintegration  of  the  cervical  portion  of  the 
cord,  whilst  Dr.  Reynolds8  considers  the  whole  trouble  to  be  due  to 
"  perverted  nutrition  of  the  parts  themselves." 

On  the  other  hand,  Dr.  Zuradelli  (lac.  cit.),  who  has  given  us  one  of 
the  most  careful  treatises  upon  the  subject,  is  strongly  of  the  opinion 
that  these  over-movements  "are  true  spasms,  but  are  due  to  paralysis  of 
one  or  the  other  muscles  used  in*  writing,  in  consequence  of  which  the 

1  De  l'Electrisation  Localisee,  3d  ed.  1872. 

2  Electricity  in  Medicine  and  Surgery,  p.  188. 

3  Gaz.  Med.  Ital.  Lombardia,  No.  36-42.  1857. 

4  Lib.  cit.,  p.  188. 

5  Jour,  de  Therap.    Paris,  1882,  ix.  121-131. 

6  Scriveners'  Palsy,  London,  1870. 

7  Lectures  on  Scriveners'  Palsy,  Lancet,  Lond.,  Jan.  1865. 
Keynolds's  System  of  Medicine,  vol.  ii.  pp.  285-292. 


454 


Robins,  Writers'  Cramp. 


[April 


antagonizing  muscles  get  the  mastery  and  occasion  a  spurious  cramp."  In 
these  views  he  is  supported  by  the  treatises  of  Geigel,1  Haupt,2  and 
Meyer.8  Zuradelli  discusses  very  elaborately  the  various  acts  necessary 
in  writing,  the  muscles  employed,  and  most  consistently  calls  these 
spasms  irritable  weaknesses.  He  finds  in  the  affected  muscles  a  diminu- 
tion in  tonicity  and  electric  irritability  and  an  intense  feeling  of  fatigue  after 
employment.  Mr.  Solly  (loc.  cit.),  in  criticizing  this  theory,  says,  "  It  is 
not  a  simple  paralysis  of  muscular  power  which  we  have  to  deal  with. 
The  patient  can  call  all  his  muscles  into  action ;  but  he  cannot  bring  them 
into  such  harmonious  action  as  to  be  able  to  write." 

Finally  Fritz,  quoted  by  Dr.  Erb  in  his  treatise  on  the  subject,4  advances 
the  hypothesis  that  "  in  writers'  spasm  there  is  a  reflex  spasm  proceeding 
from  the  sensory  cutaneous  or  sensory  muscle  nerves."  I  think  it  prob- 
able that,  whilst  this  reflex  spasm  existed  in  the  case  or  cases  under  his 
observations,  there  was  a  coincident  centric  disease  as  well. 

As  to  the  more  specific  location  of  the  lesion  in  the  central  nervous 
system,  it  will  be  found  that  most  of  the  writers  who  hold  the  first  theory 
are  agreed  in  locating  it  in  the  cervical  portion  of  the  cord.  Erb,  how- 
ever, will  not  even  commit  himself  to  this  ;  he  says  (lib.  cit.,  p.  355)  :  "  In 
the  present  state  of  our  knowledge  we  are  justified  in  placing  the  seat  of 
the  cause  of  the  typical  forms  of  writers'  spasm  in  the  central  nervous 
system,  although  we  are  not  in  a  position  to  locate  it  with  precision. 
Whether  the  trophic  disturbance  is  to  be  sought  for  in  the  gray  substance 
of  the  cervical  portion  of  the  spinal  cord,  or  in  the  cerebral  peduncles, 
or,  lastly,  in  the  gray  substance  of  the  brain,  can  only  be  determined  by 
future  investigation." 

Dr.  Stone  has  reported  a  curious  case  which  seems  to  bear  directly 
upon  the  localization  of  the  writing  centres.5    It  is  briefly  as  follows  : — 

A  prominent  English  musician  had  suffered  from  scriveners'  palsy  for  nine 
years,  during  which  time  he  had  been  treated  with  temporary  alleviation  by  the 
use  of  the  continued  and  induced  current.  He  was  also  the  subject  of  cardiac 
disease  (mitral  systolic  murmur)  and  constitutional  gout.  He  had  an  attack  of 
cerebral  embolism,  involving  the  right  side  of  the  body.  Upon  recovery  from 
this  seizure  his  palsy  had  disappeared.  The  agraphia  from  the  palsy  had  been 
at  times  ' '  complete  and  sufficient  to  require  the  aid  of  an  amanuensis ;  at  other 
times  the  '  strokes  '  of  the  letters,  both  '  upstrokes '  and  '  downstrokes, '  were 
regularly  serrated  with  small,  vibratory  oscillations  of  a  period  of  about  one-fifth 
or  one-sixth  of  a  long-tailed  letter."  Dr.  Stone  adds  :  "My  theory  as  to  the 
etiology  of  this  remarkable  case  is  that  the  temporary  and  partial  starvation  of 
the  writing  centre,  from  obstruction  of  its  blood  supply,  reduced  it  from  spasmodic 
and  over-excited  action  to  very  nearly  its  normal  state  ;  and  that,  in  fact,  the  two 
morbid  conditions  neutralized  one  another  by  opposite  actions." 

1  Die  Schreibekr.  u.  die  functionellen  Krampe  u.  Lahmungen,  Wiirzburg  Med. 
Zeitschrift,  1864. 

2  Ueber  die  Schreibekrampf. ,  Wiesb.  1860. 

3  Z.  Ther.  des  Schreibekr.  Verh.  d.  Berl.  Aerztl.  Ges.  i.  1867. 

4  Ziemssen's  Cycloped.  of  Pract.  of  Med.,  Amer.  ed.,  vol.  xi.  pp.  315-359. 

5  St.  Thomas's  Hospital  Reports,  vol.  xii.  pp.  67-75. 


1885.] 


Robins,  Writers'  Cramp. 


455 


Whatever  may  be  the  view  taken  of  this  interesting  and  curious  case,  I 
am  of  the  opinion  that,  in  the  present  state  of  our  knowledge  on  the  sub- 
ject, and  in  view  of  the  cases  reported  where  the  history  was  strongly 
against  the  attributing  of  the  lesion  to  the  periphery,  we  cannot  but  accept 
the  theory  that  the  place  of  the  disease  is  in  the  central  nervous  system.1 
As  to  the  more  exact  localization  of  the  lesion,  we  must  leave  it  for  the 
present  a  res  non  adjudicata. 

The  disease  is  not  apt  to  occur  in  early  life,  being  rarely  seen  in  indi- 
viduals under  thirty  years  of  age.  I  have,  however,  seen  a  form  of  over- 
movements  in  writing  occurring  in  a  young  lady  not  over  three-and- 
twenty  ;  but  in  her  case  the  disease  was  not  apparently  due  to  overstrain. 
As  far  as  I  can  ascertain,  none  of  the  various  authors  have  regarded  it  as 
possible  that  there  should  exist  an  hereditary  tendency  to  this  neurosis. 

The  first  symptom  which  will  be  noticed  by  the  patient  is  an  intense 
fatigue  and  stiffness  of  the  fingers,  or  a  sense  of  sluggishness  in  the  hand, 
the  pen  refusing  to  act  as  rapidly  and  as  exactly  as  is  its  wont.  Or,  on 
the  other  hand,  the  disease  may  first  introduce  itself  by  the  onset  of  an 
agonizing  cramp  of  one  or  other  of  the  muscles  of  the  thumb  or  forefinger, 
or  of  the  interossei  of  the  hand.  This  may  often  prove  a  cause  of  error  in 
diagnosis  in  the  early  stages  of  the  disease  ;  indeed,  in  two  of  the  cases 
reported  by  Dr.  Solly,  the  patients  thought  they  had  unwittingly  sprained 
the  thumb.2  If  these  premonitions  of  approaching  trouble  be  unheeded, 
and  the  disease  be  allowed  to  progress,  the  grasp  of  the  pen  will  gradually 
grow  less  firm,  and  will  have  to  be  reinforced  by  strong  contraction  of 
auxiliary  muscles,  and  even  by  forcing  the  pen  or  pencil  upon  the  paper.3 

The  first  change  in  the  handwriting  is  a  coarsening  of  the  letters  and 
a  failure  in  the  approximation  of  the  loops  of  such  letters  as  the  o  and 
the  a.  This  stage  I  have  invariably  noted  in  those  cases  which  I  have 
had  an  opportunity  to  observe,  and  it  is  especially  to  be  remarked  as  pro- 
dromal of  the  paralytic  form  of  the  disease.  It  is  unnecessary,  I  think, 
to  enter  into  a  discussion  of  the  muscles  concerned  in  making  the  small 
movements  which  produce  the  various  strokes,  which,  when  combined, 
form  writing.    Zuradelli  has  done  this  thoroughly  and  Dr.  Poore  elabo- 

1  Dr.  Romberg  (Manual  of  the  Nervous  Diseases  of  Man,  Eng.  ed.,  vol.  i.  p.  321) 
says  :  "Paralysis  of  the  upper  extremities,  dependent  on  a  cerebral  or  spinal  affection, 
frequently  commences  with  impaired  power  of  conduction  in  the  motor  nerves  of  the 
fingers,  and  consequent  difficulty  in  writing.  A  man  was  under  my  care  whose 
disease  lay  in  the  cerebellum,  and  made  its  (Ubut  with  an  impairment  in  writing." 

2  Loc.  cit. 

3  Dr.  Reynolds  has  reported  a  case  (lib.  cit.  p.  287)  in  which  "the  patient  could 
manage  to  write  a  few  words  by  moving  only  the  muscles  of  the  arm  and  trunk  ;  his 
pen  was  directed  by  the  muscles  of  his  back  and  arm,  the  latter  being  pressed  closely 
against  his  side ;  but,  after  a  few  seconds,  spasm  occurred  in  these,  the  whole  body 
was  contracted,  the  head  being  drawn  downwards  to  the  right  shoulder,  and  the 
trunk  contorted  so  as  to  render  it  concave  on  the  right  side." 


456 


Robins,  Writers'  Cramp. 


[April 


rately ;  the  curious  reader  is  referred  to  their  treatises.  I  do  not  think 
that  it  avails  much  to  give  particular  attention  to  these  minute  details, 
since  it  is  evident  even  to  the  most  casual  observer  that  no  two  indi- 
viduals employ  the  same  methods  in  writing,  and  therefore  deductions 
drawn  from  an  analysis  of  the  movements  employed  by  two  or  three  per- 
sons cannot  be  expected  to  hold  good  for  all  or  even  a  majority  of  the 
cases.  With  the  progress  of  the  disease  the  pain  or  sense  of  fatigue  pro- 
gresses also  from  muscle  to  muscle,  until  the  whole  group  employed  in 
writing  is  involved ;  in  one  of  my  patients  the  deltoid  was  the  seat  of 
pain,  and  the  arm  frequently  "went  to  sleep."  Occasionally  patients 
notice  a  feeling  of  tightness,  numbness,  or  coldness  in  the  hand  or  arm, 
and  Dr.  Reynolds  asserts  that  occasionally  there  is  actual  anaesthesia  of 
the  fingers.1  Such  are  the  earliest  symptoms  of  the  disease ;  they  are 
slightly  marked  only,  and  are  often  disregarded,  the  patient  believing 
that  he  is  affected  only  by  a  mild  cramp  of  the  arm  or  fingers,  which  will 
pass  away  before  long,  and  which  does  not  require  any  specific  treatment 
whatever.  The  following  notes  of  a  case  now  under  my  care  will  illus- 
trate the  condition  very  well : — 

Case  I. — Mrs.  A.,  get.  about  40,  has  been  for  fourteen  years  a  clerk  in 
a  public  office.  Her  duties  have  consisted  in  the  copying  of  the  written 
portions  of  certain  set  forms,  averaging  from  seven  to  ten  words,  on 
sheets  prepared  for  the  purpose.  Until  the  last  three  years  her  duties, 
although  arduous,  have  not  been  excessive,  but  of  late  the  business  has 
so  much  increased  that  it  has  often  been  necessary  for  her  to  copy  up- 
wards of  twelve  hundred  of  these  forms  during  a  day  of  (say)  six  hours  ; 
that  is  about  three  a  minute,  providing  she  works  steadily.  Of  course 
this  excessive  work  has  not  been  without  its  effect  upon  her.  The  first 
symptom  of  which  she  took  any  notice  was  a  sensation  of  intense  fatigue 
and  pain  in  the  thumb  and  forefinger ;  these  have  gradually  extended 
until  all  the  muscles  employed  in  writing,  even  the  deltoid  and  the  pec- 
toralis,  have  been  involved.  This  sensation  usually  begins  after  about 
an  hour  and  a  half  of  writing,  and  towards  the  end  of  the  day  a  marked 
cramp  of  the  muscles  sets  in,  so  that  it  is  well-nigh  impossible  for  her  to 
hold  her  pen.  At  times  sensation  is  almost  gone,  and  it  is  a  common 
occurrence  for  her  arm  to  ugo  to  sleep"  at  night. 

I  have  had  an  opportunity  of  comparing  specimens  of  her  handwriting, 
and  I  find  the  differences  very  marked  and  suggestive.  Before  this  ex- 
cess of  work  her  penmanship  was  neat  and  exact;  it  is  now  coarse  and 
rough,  the  loops  of  the  o  and  s  rarely  meet,  and  it  is  indeed  more  often 
simply  the  suggestion  of  letters  than  the  letters  themselves.  This  is  the 
condition  of  the  patient  at  the  present  time.  I  ought  to  add  that  she 
states  that  after  a  month's  holiday  she  always  returns  to  work  very  ma- 
terially improved;  that  there  is  a  marked  change  in  her  handwriting,  and 
that  the  symptoms  of  fatigue,  pain,  and  anaesthesia  entirely  disappear. 

This  case  is  a  very  good  example  of  the  disease  in  its  incipiency,  and 
from  this  point  the  disease  will  develop  in  one  of  three  directions :  it  will 
be  either  (1)  spastic,  (2)  tremulous,  or  (3)  paralytic. 


i  Lib.  cit.,  p.  288. 


1885.] 


Robins,  Writers'  Cramp. 


457 


(1)  In  the  first  of  these  forms  we  have  the  true  spasm  or  over-move- 
ment as  the  prominent  symptom,  and  any  of  the  muscles  employed  in 
writing  may  be  affected,  either  the  thumb  and  forefinger,  causing  the  fin- 
gers suddenly  to  extend  and  the  pen  to  be  dropped ;  or  the  "opponens 
pollicis  with  abduction  and  coincident  flexion  of  the  index  finger,  so  that 
the  pen  is  drawn  from  the  paper  and  moved  backwards  and  forwards  in 
the  most  irregular  manner."  Of  this  nature  was  a  case  which  came 
under  my  notice  some  months  ago  : — 

Case  II. — Miss  B.,  set.  about  50,  slight,  nervous  and  excitable. 
Family  history  excellent.  About  fifteen  years  ago  noticed  pain  in  wrist, 
which  she  attributed  to  over-playing  of  the  piano,  and  to  an  incorrect 
manner  of  holding  the  pen.  The  disease  steadily  progressed  until  the 
over-movements  were  very  marked,  not  only  in  writing,  but  in  sewing, 
knitting,  and  playing.  Under  the  direction  of  her  physician  the  arm  was 
rubbed  daily  with  stimulating  lotions,  was  douched  with  hot  and  cold 
water,  and  for  three  or  four  months  the  faradic  current  was  applied,  at 
first  daily,  then  three  or  four  times  a  week.  No  sensible  amelioration 
was  produced  in  the  disease,  but  after  she  learned  to  write  with  her  left 
hand  all  the  over-movements  disappeared  with  the  exception  of  a  curious 
spasmodic  contraction  of  the  pronator  muscles.  This  occurred  with 
greater  or  less  frequency,  according  to  the  condition  of  her  general 
health.  She  also  noticed  that  when  writing  with  her  left  hand  spasmodic 
movements  were  excited  in  her  right  arm.  Her  "right  arm  was  always 
working  when  she  wrote  with  her  left." 

In  the  autumn  of  1883  she  came  under  my  care,  at  that  time  suffering 
from  a  severe  attack  of  neurasthenia.  She  was  treated  by  rest  and  mas- 
sage, and  milk  and  beef-juice.  She  made  a  good  recovery,  and  at  the 
same  time  noted  a  marked  improvement  in  the  over-movements.  Though 
they  still  persist,  it  is  by  no  means  to  so  great  an  extent  as  before,  and 
this  improvement  has  continued  for  nearly  ten  months.  She  writes, 
sews,  and  knits  indifferently  with  her  right  and  left  hands,  but  she  asserts 
that  even  now,  if  she  sews  too  long  with  her  right  hand,  she  notices  a 
tingling  and  partial  anaesthesia  of  the  hand,  and  the  over-movements 
of  the  pronator  muscles  become  more  frequent. 

I  saw  a  similar  case  of  over-movement  several  months  ago  in  a  banker 
of  this  city.  The  spasm  in  his  case,  however,  was  in  the  supinators.  He 
is  using  now  for  writing  a  modification  of  Velpeau's  apparatus,  which 
he  says  has  proved  satisfactory. 

Zuradelli  asserts  that,  occasionally,  if  writing  be  persisted  in  in  spite 
of  the  over-movements,  the  spasm  will  progress  to  muscles  not  especially 
used  in  writing  ;  and  that  sometimes  all  the  muscles  of  the  hand,  arm,  and 
shoulder  will  be  affected.  In  every  case,  he  says,  he  has  found  a  diminu- 
tion of  muscular  tonicity  and  electric  irritability. 

(2)  The  tremulous  form  of  the  disease  is  very  well  illustrated  in  the 
case  reported  by  Dr.  Stone  and  already  quoted.  In  a  case  which  I  have 
seen,  and  of  which  I  have  a  specimen  of  the  handwriting,  I  have  counted 
no  less  than  fourteen  curves  in  the  formation  of  the  capital  letter  T,  and 
thirteen  in  the  letter  N. 


458 


Robins,  Writers'  Cramp. 


[April 


(3)  The  third  form  of  spasm  is  nearly  as  common  as  the  first,  and 
is  directly  progressive  from  the  symptoms  of  pain  or  fatigue  which  have 
been  mentioned  as  an  early  symptom  of  the  disease ;  the  exhaustion  and 
weakness  increase,  and  finally  it  is  impossible  for  the  patient  to  write 
more  than  three  or  four  words  before  the  muscles  absolutely  refuse  to  act. 

It  is  to  be  remarked  that  it  is  generally  a  characteristic  of  all  the  forms 
of  the  disease  that  other  co-ordinating  muscular  actions  of  the  affected  part 
are  not  followed  or  complicated  by  over-movemenis.  The  writer  can 
carve,  drive,  and  shave  without  the  occurrence  of  any  spasm  ;  so  also  the 
tailor  and  cobbler  can  write,  the  pianist  can  sew,  and  the  artist  can  play 
the  violin,  without  the  intimation  of  any  involuntary  movement,  but  let 
that  special  and  complicated  movement  which  has  become  the  subject  of 
disease  be  attempted,  and  over-movements  are  sure  to  follow.  This  rule, 
however,  does  not  hold  in  all  cases ;  for  instance,  Miss  B.  suffered  from 
over-movements  following  several  coordinative  muscular  acts,  and  Dr. 
Poore  has  reported  two  cases1  in  which  carving,  writing,  shaving,  and 
driving  were  all  complicated  by  over-movements. 

Enough  has  been  said  with  regard  to  the  symptoms  of  this  disease  to 
make  the  diagnosis  easy.  The  prognosis  should  always  be  guarded. 
But  when  an  uncomplicated  case  of  scriveners'  palsy  is  taken  early 
enough,  say  in  the  first  stage,  or  even  before  the  second  stage  is  well  ad- 
vanced, and  when  absolute  rest  can  be  secured,  and  when  finally  there 
exists  in  the  affected  muscles  some  faradic  irritability,  I  see  no  reason 
why  such  a  case  should  not  recover.  On  the  other  hand,  the  scores  of 
cases  which  have  come  out  from  treatment  only  temporarily  relieved  warn 
us  that  we  should  be  wary  of  rashly  promising  absolute  recovery.  Dr. 
Poore,  indeed,  reports  a  case2  which  had  lasted  for  ten  years,  in  which 
there  were  marked  pain  and  over-movement,  and  in  which  there  was  ulti- 
mate recovery  after  a  six  months'  treatment,  consisting  of  absolute  rest, 
galvanism,  and  nervines.  Such  a  recovery,  however,  must  be  regarded 
as  entirely  exceptional. 

Now,  given  a  patient  in  whom  these  over-movements  exist,  what 
should  be  the  treatment  ?  In  the  first  place,  there  is  one  absolutely  essen- 
tial factor  in  the  treatment  of  all  cases  in  which  recovery  is  hoped  for, 
and  that  is  absolute  rest.  No  case  can  possibly  improve  to  any  great  ex- 
tent without  it.  By  rest  is  meant  entire  cessation  from  all  those  coordi- 
native movements  which  are  attended  with  pain,  fatigue,  or  spasm.  For 
other  movements  the  arm  may  be  used,  but  the  writer  must  lay  aside  his 
pen,  the  violinist  his  instrument,  and  the  seamstress  her  needle,  during 
the  whole  period  of  treatment.  In  order  to  insure  restoration  I  have  in 
one  or  two  cases  ordered  the  arm  to  be  carried  in  a  sling  during  the  first 
week  of  treatment.    If  there  be  any  atrophy  of  the  muscles,  stimulating 


1  Lib.  cit.,  p.  219. 


2  Practitioner,  London,  Sept.  1872. 


1885.] 


Kobins,  Writers'  Cramp. 


459 


lotions,  with  rapid  friction,  may  'be  employed;  and  I  have  seen  good 
effects  follow  alternate  douching  with  hot  and  cold  water.  Calisthenics 
have  also  been  suggested,  and  may  be  approved  if  addressed  especially  to 
the  affected  muscles. 

Massage  in  cases  of  over-movement  was  first  suggested  by  "Wolff,  and 
his  results  and  method  were  published  by  Vigouroux1  in  1882.  Briefly, 
his  method  "rests  exclusively  upon  active  and  passive  gymnastics  of  the 
fore  and  upper  arm,  upon  massage,  percussion,  and  friction  of  the  same 
parts,  and  after  a  time  elementary  exercises  in  writing  prescribed  and 
adapted  to  each  case  by  holding  the  pen  in  a  definite  manner.  These 
are  gone  through  with  two  or  three  times  daily  for  half  an  hour  or  so  at 
a  time."2  It  is  claimed  that  by  this  method  Wolff  cured  157,  improved 
22,  and  effected  no  change  in  98,  out  of  277  cases  of  over-movement. 
The  duration  of  treatment  averaged  three  weeks.  Massage  has  an  earnest 
advocate  in  Dr.  Douglas  Graham,  of  Boston,  who  has  recently  published 
a  treatise3  in  which  he  strongly  endorses  the  treatment  of  over-movements 
by  massage. 

Finally,  in  electricity  we  have  a  most  important  factor  in  the  treatment 
of  these  neuroses,  although  the  experience  of  Zuradelli  and  others  would 
seem  to  indicate  that  good  results  are  not  to  be  expected  in  the  majority 
of  cases  when  reliance  is  placed  chiefly  upon  the  battery.  Dr.  Poore,  in 
his  excellent  hand-book  already  mentioned,  points  out  the  fact  that  almost 
all  these  failures  have  followed  the  use  of  the  faradic  current.  In  his 
hands  the  use  of  the  continuous  current  has  generally  been  followed  by 
improvement,  and  he  strongly  advises  against  the  use  of  the  faradic  cur- 
rent as  being  too  powerful  a  stimulant,  and  carrying  with  it  the  danger  of 
extinguishing  the  faint  spark  of  electric  irritability  which  may  remain  in 
the  worn-out  muscle.  His  method  of  using  the  continuous  current  is  as 
follows  : — 4 

"One  pole  (the  positive)  is  placed,  let  us  say,  in  the  axilla,  and  the  other 
over  the  ulnar  nerve  just  where  it  leaves  the  biceps  muscle  en  route  for  the 
olecranon.  The  strength  of  the  current  is  short  of  that  which  causes  muscular 
contraction,  but  is  just  sufficient  to  make  the  patient  conscious  of  a  tingle  in  the 
end  of  the  little  finger  when  the  circuit  is  made  or  broken.  The  patient  is  made 
to  exercise  the  interossei  by  separating  and  approximating  the  fingers  rhythmi- 
cally. Take  another  example  :  the  positive  pole  maybe  placed  over  the  median 
nerve  at  the  inner  border  of  the  biceps,  and  the  negative  over  the  body  of  the 
flex  or  longus  pollicis,  while  the  patient  is  made  to  flex  rhythmically  the  distal 
phalanx  of  his  thumb  ;  or,  again,  the  positive  pole  may  be  placed  in  the  axilla, 
and  the  negative  over  the  musculo-spiral  nerve  as  it  turns  forward  alongside  the 
supinator  longus  just  above  the  bend  of  the  elbow  ;  and  the  patient  is  then  made 
to  supinate  the  hand  or  extend  the  finger  rhythmically." 


1  Progres  Med.,  Paris,  Jan.  21, 1882. 

2  Th.  Stein,  Berlin.  Klin.  Woehen.,  Aug.  21, 1882. 

3  A  Practical  Treatise  on  Massage,  etc.   New  York,  1884. 

4  Electricity  in  Medicine  and  Surgery,  p.  204. 


460 


Eobins,  Writers'  Cramp. 


[April 


Professor  Erb,  consistently  with  his  theory  as  to  the  pathology  of  the 
disease,  favors  applications  of  the  continuous  current  to  the  entire  motor 
apparatus  from  the  cerebral  cortex  to  the  muscles."  He  also  advised 
local  faradization  with  strong  currents.1 

I  add  the  report  of  a  case  treated  in  accordance  with  the  method  which 
I  have  tried  to  suggest  in  these  notes  : — 

Case  III — Mr.  B.  aged  36,  small,  wiry,  of  neurotic  temperament  and 
family  history.  A  sister  has  hysteria,  and  has  had  several  attacks  of 
hystero-epilepsy,  and  his  half  brother  is  epileptic.  Has  been  a  book- 
keeper with  the  same  firm  for  over  fifteen  years.  Two  years  ago,  after  a 
great  stress  of  work  extending  over  several  weeks,  he  noticed  symptoms  of 
fatigue  and  pain  after  writing  for  an  hour  or  so.  The  disease  progressed 
rapidly  until  finally  he  was  forced  to  hold  the  pen  between  his  fingers  by 
forcing  it  on  the  paper,  and  by  strong  muscular  contraction.  The  disease 
finally  advanced  to  the  second  stage,  and  over-movements  began.  After 
writing  a  few  minutes  the  thumb  and  fingers  would  be  suddenly  jerked 
apart,  and  the  pen  would  fall  between  them.  He  became  seriously  alarmed, 
and  consulted  a  physician,  who  advised  rest  and  electricity.  He  took  a 
month's  holiday  and  went  under  treatment ;  was  faradized  three  times  a 
week,  but,  as  far  as  I  can  learn,  upon  no  particular  system.  At  the  end  of 
his  holiday  he  was  somewhat  improved,  and  returned  to  his  work  con- 
siderably encouraged,  but  after  a  month  and  a  half,  although  he  was 
careful  not  to  do  more  writing  than  was  positively  necessary,  he  found  his 
old  condition  gradually  returning.  After  struggling  with  the  disease  for 
several  months  longer,  he  came  under  my  care. 

The  case  was  not  a  promising  one.  The  faradic  irritability  of  the 
muscles  of  the  right  hand  and  arm  was  considerably  diminished  ;  the  man 
himself  was  angemic  and  nervous.  I  insisted  upon  entire  rest,  not  only 
for  the  affected  arm  but  also  for  the  whole  body,  and  to  this  end  I  ordered 
him  to  bed,  and  put  him  on  a  modification  of  the  Weir  Mitchell  Treat- 
ment for  Neurasthenia,  including  massage  four  times  a  week  especially 
directed  to  the  affected  arm, and  the  constant  current  applied  daily.  After 
the  first  week  I  allowed  him  to  leave  his  bed,  applied  the  battery  daily, 
and  continued  the  massage.  At  the  end  of  the  first  fortnight  the  improve- 
ment of  the  patient  was  so  marked  as  to  cause  me  some  astonishment. 
He  had  a  voracious  appetite,  had  gained  sixteen  pounds  in  weight,  and 
his  nervousness  and  insomnia  had  vanished.  The  faradic  irritability  of 
the  muscles  of  the  right  arm  was  considerably  increased.  Without  going 
into  the  details  of  the  history,  I  will  add  that  I  continued  this  method  of 
treatment,  gradually  diminishing  the  number  of  seances  both  of  electricity 
and  of  massage,  until  at  the  expiration  of  the  third  month  I  discharged 
the  patient  practically  well ;  though  I  must  say  that  his  handwriting  was 
still  coarse  and  ill-formed.  He  has  had  no  return  of  the  disease,  but  he 
has  given  up  his  occupation  as  a  scrivener. 

This  is  a  good  instance  of  recovery  in  a  case  in  which  all  the  conditions 
for  treatment  are  favorable,  but  the  practitioner  will  often  meet  with  cases 
in  which  it  will  be  impossible  for  the  patient,  whose  livelihood  depends 
upon  the  pen,  to  give  up,  even  for  a  short  time,  the  employment  which 


1  Hand-book  of  Electro-Therapeutics,  Amer.  ed.,  pp.  296,  297. 


1885.] 


Robins,  Writers'  Cramp. 


461 


has  induced  the  disease.  In  such  cases  the  prognosis  for  recovery  is  of 
course  unfavorable.  Writing  may,  of  course,  be  made  possible  by  the 
employment  of  some  apparatus  for  holding  the  pen  and  relieving  the 
affected  muscles.  Many  of  these  appliances  have  been  invented  ;  amongst 
others  may  be  mentioned  those  of  Cazenave,  Langenbeck,  and  Yelpeau. 
One  which  was  suggested  by  Von  Nussbaum,  of  Vienna,  seems  to  me  to 
possess  to  a  greater  degree  than  the  rest  the  advantages  of  lightness  and 
simplicity.  It  consists  of  an  oval  band  of  hard  rubber  through  which  the 
fingers  pass,  and  which  is  held  in  position  by  the  pressure  of  the  ball  of 
the  thumb.  On  the  upper  part  of  this  band  is  fastened,  by  its  base,  a 
grooved  right-angled  triangle  sloping  towards  the  fingers.  In  the  groove 
the  penholder  is  held  by  a  screw.  Writing  with  this  instrument  is  en- 
tirely from  the  wrist,  there  being  no  finger  movements,  and  the  hand 
must  be  held  in  complete  pronation. 

One  of  my  patients  derived  much  benefit  by  alternating  with  the  ordi- 
nary penholder  a  little  apparatus  which  was  made  of  an  ordinary  solid 
rubber  ball ;  this  was  perforated  at  about  one-third  of  its  circumference, 
and  a  penholder  was  thrust  through.  The  ball  was  held  in  the  hand,  and 
the  penholder  passed  up  between  the  first  and  second  fingers. 

It  will  be  evident,  however,  from  what  has  been  said,  that  these  appa- 
ratuses can  only  be  used  in  cases  where  the  mischief  is  confined  to  the 
muscles  of  the  hands  and  fingers.  If  the  pronators  and  supinators  be  also 
involved,  the  contrivances  will,  of  course,  be  useless.  And,  indeed,  in 
the  majority  of  cases,  the  practitioner  must  be  very  guarded  in  recom- 
mending any  of  them  as  likely  to  be  of  more  than  temporary  benefit. 

Bibliography. — Bruck,  Hufeland's  Jour.,  1885,  st.  4.  Stromeyer,  Uber  d.  Schrei- 
bekr.,  Bayr.  med.  Correspondenzbl.,  1840,  No.  8.  G.  Hirsch,  Spinalneurosen,  1843. 
Fritz,  Uber  Reflexions  finger  krampf,  Oesterr.  Jarb.,  1844,  Bd.  48  u.  47.  Cazenave,  de 
quelques  infirmit.  de  la  main  droite,  etc.,  Gaz.  Med.  de  Paris,  1845;  also  Casp. 
Wochenschr.,  1848,  No.  16.  Romberg,  Schreibekrampf,  Lehrbuch  der  Nerven-krank- 
heiten,  2d  ed.,  Berlin,  1851  ;  also,  Translation  by  Dr.  Sieveking,  for  the  New  Sydenh. 
Soc'y.  Guy  on,  Moyen  de  faire  cesser  immediatement  les  crarapes  des  ecrivains,  Gaz. 
Med.  de  Paris,  1852.  TMelmann,  Fall  von  Nahekrampf.,  Med.  Zeit.  Russlands,  1859, 
No.  44.  Seccamani,  Crampe  des  ecrivains  guerie  par  l'electricite,  Gaz.  Med.  de  Paris, 
1859  :  Sur  les  moyens  prothetiqnes  destines  a  prevenir  la  production  des  spasraes  pen- 
dant l'exereise  de  la  main,  et  specialement  la  crampe  des  ecrivains,  Bull,  de  Therap., 
Paris,  1860.  Haupt,  Uber  d.  Schreibekr.,  Wiesb.,  1860.  Tuppert,  Z.  Bebandl.  des 
Scbreibekr.,  Bayr.  artzl.  Intelligenzblatt,  1860,  No.  24.  Axenfeld,  Nevroses,  Pathologie 
de  Raquin,  Paris,  1863,  vol.  iii.  Oris.  Zuradelli,  Del  crampo  degli  Scrittori,  Gaz.  Med. 
Ital.  Lombard.,  1857,  Nos.  36-42;  also,  Annal.  Univers.,  1864.,  Remak,  Klin.  Mittheil., 
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paralys.  muse,  fonc,  Bull,  de  Therap.,  1860;  also,  De  l'electris.  localis.,  iii.  ed.  1872. 
Geigel,  Die  Schreibekr.  u.  die  functionellen  Krampfe  u.  Lahmungen,  Wurzb.  Med. 
Zeitschrift,  1864.  Solly,  Lectures  on  Scriveners'  Palsy,  Lancet,  London,  Jan.  1865,  and 
May,  1867.  Valleix,  Guide  du  Medecin  practicien,  5th  ed.,  Revue  par  Lorain,  Paris, 
1866,  vol.  i.  M.  Meyer,  Z.  Ther.  des  Schreibekr.,  Verb.,  d.  Berl.  arztl.  Ges.  i.  1867. 
Reynolds  {J.  R.),  Writers'  Cramp,  Reynolds's  System  of  Med.,  Am.  ed.  Phila.,  1868, 
ii.  285-292.  Simon,  Crampe  des  ecrivains,  Nouv.  Diet,  de  Med.  et  de  Chirurg.  Prat., 
Paris,  1869,  x.  144-147.  Althaus,  Scriveners'  Palsy,  London,  1870.  Buzzard,  Writers' 
Cramp,  Practitioner,  London,  Aug.  1872.  Poore,  Case  of  Writers'  Cramp,  Practi- 
ce CLXXVIII  April,  1885.  30 


462         Oliver,  A  Correlation  Theory  of  Color-perception.  [April 


ticraer,  London,  Sept.  1872  ;  also,  Practitioner,  London,  vol.  ii.  1873.  Bunge,  Z.  Genese 
u.  Ben.  des  Schreibekr.,  Berl.  Klin.  Wocli.,  1873,  No.  21.  Bossander,  Hygeia,  July, 
1873.  Gottlieb,  Virchow  and  Hirsch's  Jahresbericht,  1874.  Drachmann,  Schmidt's 
Jahrbucher,  1875.  Poore,  Electricity  in  Medicine  and  Surgery,  London,  1876.  Erb, 
Writers'  Cramp,  Ziemssen's  Cycloped.  of  Pract.  of  Med.,  Amer.  ed.  1876,  vol.  xi.  345- 
359.  Eulenberg,  Handbuch  der  Krankheiten  Nervensystems,  Leipzig,  1876.  Hasse, 
Handbuch  der  Speciellen  Pathol,  und  Therap.  (Virchow),  1876,  iv.  149.  Poore,  An 
Analysis  of  75  Cases  of  Writers'  Cramp  and  impaired  Writing  Power,  Med.-Chir. 
Trans.,  London,  1878,  lxi.  111-145;  also,  Lancet,  London,  1878,  i.  236-238.  Beard, 
Conclus.  from  the  Study  of  125  Cases  of  Writers'  Cramp  and  allied  Affections,  Med. 
Eec,  N.  Y.,  1879,  xv.  244-247;  also,  Tr.  M.  Soc.  N.  V.,  Syracuse,  1879,  379-390. 
Putnam,  A  new  adjuvant  in  the  Treatment  of  Writers'  Palsy,  Boston  M.  and  S.  Jour., 
1879,  ci.  320.  Napias,  Note  surun  nouveau  cas  de  crampe  professionnelle,  Eev.  d'Hyg., 
Paris,  1879,  i.  927-930;  also,  Bull.  Soc.  de  Med.  Pub.  1879,  Paris  (1880),  ii.  267-270. 
Whittaker,  Writers'  Cramp,  Cincinnati  Lancet  and  Clinic,  1880,  N.  S.,  iv.  496  ;  also, 
Detroit  Lancet,  1880,  iv.  97-99.  Waller,  Early  avoidance  of  Writers'  Cramp,  Prac- 
titioner, London,  1880,  xxv.  101-103.  Paul,  Du  traitement  du  tremblement  et  des 
autres  troubles  de  la  co-ordination  du  mouvement  par  les  bains  galvaniques,  Tribune 
Med.,  Paris,  1880,  xiii.  495-499.  Frazer,  On  the  Pathol,  of  Writers'  Cramp,  with  illus- 
trative cases,  Glasgow  Med.  Jour.,  1881,  xv.  169-179.  Lombard,  Due  casi  di  mogi- 
graphia curati  coll'  elettricita  ;  appunti  clinico-terapeutics,  Imparziale,  Eirenze,  1881, 
xxi.  225-231.  Paul,  Crampe  des  ecrivains,  Bull,  et  Mem.  Soc.  de  Therap.,  Paris,  1881, 
xiii.  129-131.  Webber,  Writers'  Cramp  and  allied  Affections,  Clyclop.  Pract.  Med. 
(Ziemssen),  N.  Y.,  1881,  523-525.  Poore,  The  "Bradshawe"'  Lecture  on  Nervous 
Affect,  of  the  Hand,  Lancet,  London,  1881,  ii.  495-498  ;  also,  Med.  Times  and  Gaz., 
London,  1881,  ii.  349-354.  Maguelssen,  Stotte  apparater  til  Brug.  ved  Skrivekrampe, 
Norsk.  Mag.  f.  Lsegevidensk,  Kristiana,  1881,  xi.  948-952.  Vigouroux,  Du  traitement 
de  la  crampe  des  ecrivains  par  la  methode  de  Wolff,  Progrds  Med.,  Paris,  1882,  x.  37. 
Dalby,  Etiologie  et  traitement  des  spasmes  professionals  (Crampes,  contractures,  etc.) , 
Jour,  de  Therap.,  Paris,  1882,  ix.  121-131.  Bobinson,  Cases  of  Telegraphists'  Cramp, 
Brit.  Med.  Jour.,  Lond.,  1882,  ii.  880.  Th.  Stein,  Berlin  Klin.  Woch.,  Aug.  21, 1882. 
Schiit",  Zur  Behand.  des  Schreibekr.,  Prag.  Med.  Wochenschr.,  1883, viii.  73-75.  Von 
Nussbaum,  Einfache  und  erfolgreiche  Behandlung  des  Schreibekr.,  eine  voiTaufige 
mittheilung,  2  aufi.  Miinchen,  1883.  Stone,  Some  effects  of  Brain  Disturbance  on  the 
Handwriting,  St.  Thomas's  Hosp.  Reports,  1883,  xii.  67-75.  Erb,  Handbook  of 
Electro-Therapeutics,  trans,  by  L.  Putzel,  N.  Y.,  1883,  295-297.  Cappellani,  Nevrosi 
degli  Scrivani,  Gior.  di  Clin,  e  terap.,  Messina,  1883,  ii.  97-105.  Meynert,  Uber  func- 
tionelle  nerven  krankheiten,  auz.  d.  kk.  Gesellsch.  d.  aerzte  in  Wien,  1882-83, 158-161. 
Morton,  Treatment  of  Writers'  Cramp,  Jour.  Nerv.  and  Ment.  Dis.,  N.  Y.,  1883,  x. 
503-507.  Fulton,  Telegraphists'  Cramp,  Edinb.  Clin,  and  Path.  Jour.,  1883-4,  i.  369- 
375.  Wolff,  Treatment  of  Writers'  Cramp  and  allied  Muscular  Affect,  by  Massage 
and  Gymnastics,  Med.  Rec,  N.  Y.,  1884,  xxv.  204.  Bramicell,  Lecture  on  Co-ordina- 
tion of  Movement  and  its  Derangements,  Lancet,  London,  1884,  i.  285-287.  McDon- 
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Schreibekr.  und  verwandt.  muskelaff'ection.,klavier,telegraphier,violinskr.,etc,  nach 
eigener  neuer  methode,  Frankf.  a.  M.  1884.  Graham,  Practical  Treatise  on  Massage, 
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No.  1259,  pp.  323,  324. 


Article  XIII. 

A  Correlation  Theory  of  Color-perception.  By  Charles  A.  Oliver, 
A.M.,  M.D.,  one  of  the  Ophthalmic  and  Aural  Surgeons  to  St.  Mary's  Hos- 
pital, Philadelphia. 

In  an  article  upon  this  subject,  which  was  published  in  the  preceding 
number  of  this  Journal,  the  correlation  theory  of  perception  and  the  sup- 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  463 


port  it  received  from  physiological  research  was  discussed.  In  the  present 
paper  we  propose  to  still  further  test  its  correctness  by  the  pathological 
data  at  our  command. 

Pathological  Data  Here,  where  the  degree  of  vitality  of  lowered 

sensory  material  is  made  evident  by  the  study  of  correspondingly  faulty 
results  of  physiological  power,  positive  proofs  as  to  the  genuineness  of  the 
supposed  character  of  the  normal  working  machinery,  and  of  its  probable 
mode  of  action,  can  be  thus  indirectly  obtained.  This  can  best  be  clone 
by  study  of  the  condition  known  as  "  color-blindness."  From  time  im- 
memorial it  has  been  known,  but  not  until  quite  recently  has  its  pre- 
sence been  tested  for,  as  a  means  of  diagnosis  in  those  still  obscure  changes 
which  give  rise  to  its  existence.  Numerous  fragmentary  accounts  of  im- 
perfectly observed  varieties  could  be  cited,  where,  although  symptomatic 
facts  stood  staring  the  observer  in  his  face,  yet  on  account  of  the  rarity  of 
proper  instruments  of  detection,  and  by  reason  of  the  primitiveness  of  the 
current  methods  of  precision,  the  observations  were  of  such  little  value  as 
to  render  them  mere  curiosities  to  the  present  student.  For  these  reasons 
it  has  not  been  deemed  necessary  to  spend  any  time  in  their  relation. 

When  the  great  disproportion  between  the  vast  number  of  "  natural 
colors"  and  the  limited  amount  of  "  sensory  colors "  is  considered,  the 
conclusion  that  must  be  logically  drawn  is,  that,  normally,  every  visual 
mechanism  is  physically  and  physiologically  fitted  to  respond  to  but  a 
small  amount  of  the  great  bulk  of  natural  color  vibrations,  thus  virtually 
proving  that  every  such  mechanism  is  truly  "  color-blind."  Guillemin 
says1  that  M.  Chevreul  was  able  to  distinguish  and  designate  fourteen 
thousand  four  hundred  and  twenty  "  tones"  of  color.  At  first  sight,  this 
seems  wonderful — wonderful  because  it  is  exceptional,  and  yet  even  in 
this  instance,  the  thought  arises,  how  many  billions  of  color  differences 
there  were  still  to  perceive,  and  how  meagre  the  vaunted  attainments  of  the 
imperfect  color-seeing  organ  !  The  fact  that  there  is  a  limit  for  color- 
perception  can  be  explained  by  comparison  with  the  physiological  powers 
of  one  of  the  lower  senses.  Helmholtz,2  by  a  series  of  experiments,  has 
fixed  the  lowest  limit  of  natural  vibratory  tone  which  is  perceptible  to  the 
auditory  apparatus  of  the  human  species,  as  one  of  about  sixteen  vibra- 
tions to  the  second,3  and  the  highest  at  a  little  more  than  thirty-eight 
thousand  vibrations  per  second  :  this  latter  number,  as  shown  by  Turn- 
bull,4  is  about  the  limit  for  the  ordinary  untrained  human  ear,  although, 

1  "  The  Forces  of  Nature,"  etc.    Eng.  translation  by  Mrs.  Norman  Lockyer,  1873. 

2  £<  Die  Lehre  von  den  Tonempfindungen,"  etc.,  1870. 

3  Savart  placed  the  deepest  perceptible  tone  at  a  point  equivalent  to  but  eight  com- 
plete vibrations  in  a  second's  time. 

4  Journal  of  the  American  Medical  Association,  Nov.  29,  1884,  p.  591.  (Turnbull 
really  estimated  a  fraction  over  forty  thousand,  as  the  average  result  for  the  normal 
and  healthy  auditory  apparatus.) 


464         Oliver,  A  Correlation  Theory  of  Color-perception.  [April 

in  one  instance  cited,  a  tone  of  sixty  thousand  natural  vibrations  to  the 
second  was  perceptible.  Even  granting  that  the  most  distant  extremes 
recorded  are  correct,  yet  even  here  the  proportion  in  numbers  between 
sensible  sound  and  natural  sound  is  so  exceedingly  great,  that  the  amount 
of  each  is  in  no  degree  comparable.  These  results  with  a  lower  sensory 
organ  show  that  similar  limits  of  physiological  action  from  imperfect 
mechanism  must  be  expected  from  the  higher  sense — vision.  Moreover, 
the  human  visual  apparatus  as  it  now  exists,  through  inherent  want  of 
adequate  working  machinery,  is  unable  to  receive  for  perception  every 
grade  of  natural  color  impression  existing  between  the  usually  recognized 
terminals  (red  and  violet)  of  ordinary  spectra.  All  that  has  been  said  in 
reference  to  the  low  value  of  ChevreuPs  seeming  great  ability  of  color 
differentiation  can  be  applied  here  just  as  well  as  in  the  other  argument. 
Billions  of  unrecognized  natural  color-differences  exist  between  the  red 
and  the  violet  ends  of  the  ordinary  solar  spectrum,  colors  that,  through 
want  of  power  of  receipt,  transmission,  and  perception,  may  forever  re- 
main unknown.  Examples  in  support  of  this,  based  upon  "  sound-deaf- 
ness,"1 may  be  given.  "Wollaston  mentions2  that  certain  individuals  who 
possess  a  sensitive  ear  for  low  sounds  are  often  unable  to  recognize  very 
acute  sounds.  He  says  that  frequently  for  such  persons,  the  chirp  of  the . 
grasshopper  and  the  cry  of  the  bat  are  inaudible,  and  cites  one  case 
where  the  chirrup  of  the  common  house  sparrow  was  not  heard  at  all. 
He  instances  a  personal  failure  in  recognizing  the  cry  of  an  unknown 
species  of  gryllus,  which  was  distinctly  heard  by  some  young  friends. 
Herschel  writes  :  "  Nothing  can  be  more  surprising  than  to  see  two  per- 
sons, neither  of  them  deaf,  the  one  complaining  of  the  penetrating  shrillness 
of  a  sound,  while  the  other  maintains  there  is  no  sound  at  all."3  Tyndall 
speaks  of  an  instance  which  occurred  in  his  own  life,4  when  crossing  the 
Wengern  Alp  in  company  with  a  friend.  He  says :  "  The  grass  at  each 
side  of  the  path  swarmed  with  insects  which  to  me  rent  the  air  with  their 
shrill  chirruping.  My  friend  heard  nothing  of  this,  the  insect-music  lying 
quite  beyond  his  limit  of  audition."5  Reasoning  from  these  examples  of  in- 
adequacy in  the  action  of  a  lower  sense  shows  conclusively  that  each  normal 
human  color-seeing  organ  of  the  present  type  has  a  certain  innate  physical 
inability  which  prevents  the  perception  of  every  spectral  color.    In  support 

1  An  imperfect  term  comparable  with  "  color-blindness,"  first  made  use  of  by  the 
author,  in  the  Phila.  Med.  Times,  Jan.  28,  1882. 

2  Philos.  Trans.,  1820,  p.  306  et  seq. 

3  Tyndall  on  "  Sounds,  etc.,"  p.  73.  4  Ibid.,  p.  73. 

5  In  these  citations  it  is  impossible  to  say  how  much  of  the  peculiar  conditions  was 
due  to  acquired  pathological  change,  but  it  is  evident,  from  the  manner  of  observation 
and  che  purpose  of  the  observer,  that  they  are  most  probably  illustrative  of  normal 
idiosyncrasy.  Individual  experience  has  contributed  to  the  author's  mind  at  least 
that  there  are  many  such  cases  to  be  found  in  our  everyday  existence. 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  465 


of  this,  Pereira  remarks  :l  "  It  is  highly  probable,  however,  that  the  range 
of  human  vision,  like  that  of  hearing,  is  subject  to  variation  in  different  indi- 
viduals." He  broadly  asserts  that  "  there  is  a  limit  to  the  sensibility  of 
both  ear  and  eye,"  which  statement  he  makes  fuller  by  saying  "  that  is, 
a  certain  number  of  impulses  must  be  made  in  a  given  time  on  these 
organs  ;  and  if  we  go  on  augmenting  the  number,  we  cease  to  be  sensible 
of  them  after  a  certain  time."  Superadded  to  this  want  of  capability  of 
certain  sensory  elements  to  be  more  freely  acted  upon,  there  is  another 
factor  which  is  dependent  upon  individual  lack  of  training  and  want  of 
education,  i.  e.,  a  true  deficiency  of  functional  activity.  This  should  not 
be  confounded  with  the  former,  as  this  latter  factor  is  merely  a  want  of 
physiological  action,  and  has  no  practical  bearing  upon  the  subject.  It 
partly  solves  the  riddle  why  the  percentage  of  deficient  color-sense  is  so 
much  lower  in  the  female  sex  than  it  is  in  the  male  sex.  Independent  of 
the  fact,  based  upon  the  still  vague  laws  of  heredity,  especially  as  exem- 
plified by  the  transmission  of  imperfect  material  for  color-vision,  that  con- 
genital defects  are  most  generally  brought  forward  in  succeeding  lines  of 
generation  by  unattacked  females  giving  birth  to  diseased  sons,  women 
will  differentiate  colored  materials  more  accurately  as  long  as  the  female 
lines  of  generation  shall  continue  to  live  amongst  natural  colors,  and  men 
need  never  hope  to  attain  so  good  a  system  of  grading  until  the  choice 
and  selection  of  such  colors  shall  become  a  similar  routine  duty.  It  is  an 
incontrovertible  fact  that  if  any  proportion  of  a  number  of  similar  visual 
apparatuses  should  be  reared  amongst  colors,  they  would  give  far  better 
results  in  color-perception  than  those  not  so  happily  situated:  this  can  be 
illustrated  by  the  ability  of  the  male  operatives  of  a  large  dental  depot  in 
this  city  to  tell  at  a  glance  the  trade  number  of  a  tint  of  enamel  in  a  set 
of  artificial  teeth  from  more  than  fifty  varieties.  Skilful  musicians  have 
by  long  practice  enabled  themselves  to  enjoy  musical  sounds  which  are 
wholly  ignored  by  less  trained  auditory  apparatuses.  Education  and  ex- 
perience have  created  or  brought  into  activity  other  correlated  perceptive 
elements  of  hearing  that  have  either  been  newly  made  or  have  for  a  long 
time  remained  dormant  and  unused.  To  aver  that  a  person  whose  color- 
perception  material  is  not  trained  to  detect  delicate  differences  of  color,  is 
physically  "  color-blind,"  would  be  as  ridiculous  as  to  declare  that  an 
uneducated  and  unused  muscle  is  incapable  of  proper  action  if  correct 
stimulus  should  be  regularly  and  periodically  applied.2  Every  normal 
color  apparatus  has  an  idiocratic  and  definite  amount  of  fault  in  color- 
perception,  dependent  upon  two  separate  factors.  First,  a  physical  inca- 
pability ;  and,  secondly,  a  want  of  physiological  action.  The  first  factor 
should  be  subdivided  into  two  conditions,  in  one  of  which  there  is  a  limit 

1  Lectures  on  Polarized  Light,  etc.,  by  Jonathan  Pereira,  1851,  p.  80. 

2  Phila.  Med.  Times,  Jan.  28,  1882,  pp.  282-285. 


466         Oliver,  A  Correlation  Theory  of  Color-perception.  [April 


in  the  extent  of  the  visible  or  human  color  spectrum,1  and  in  the  other 
where  there  are  breaks  or  hiatuses  in  this  visible  color  spectrum  ;  both 
conditions  being  caused  by  either  the  primary  want  of  proper  physical 
material,  or  the  subsequent  loss  of  responsive  nerve-substance  through 
disuse.  The  second  factor  is  called  into  play  either  when  there  never  has 
been  a  presentation  of  the  natural  color-stimulus,  or  where  the  physiolo- 
gical action  has  been  so  slight  (either  in  amount  or  duration)  as  to  give 
but  a  faint  and  improper  perception. 

If  the  assumption  be  true  that  each  individual  in  the  human  species 
has  a  definite  amount  of  the  so-called  "color-blindness,"  then  it  remains 
only  to  find  those  cases  in  which  the  condition  becomes  so  marked  as  to 
assume  the  character  of  recognizable  fault.  At  this  latter  point,  the 
usual  signification  of  the  popular  definition  of  "  color-blindness"  has  been 
reached,  and  the  faulty  color-seeing  organ  must  be  placed  on  the  patho- 
logical side  of  the  question.  So  arbitrary  is  this  point,  so  different  are 
the  acceptances  of  authoritative  reasoning  as  to  the  choice  of  its  position, 
and  so  limited  are  the  means  for  discrimination,  and  crude  the  data  for 
average  normalization,  that  it  becomes  impossible  at  the  present  time  to 
give  any  positive  basis  upon  which  to  place  the  abnormity.  All  that  can 
be  said  is,  that,  if  there  either  should  arise  a  noticeable  defect  in  color- 
vision  during  the  life  of  a  visual  apparatus,  or  if  there  should  be  a  recog- 
nizable similar  condition  which  has  manifested  itself  from  the  first  use  of 
the  working  material  of  the  apparatus,  then  the  individual  may  be  desig- 
nated as  one  with  lowered  color-vision  ;  the  recognition  of  the  fault  being 
entirely  dependent  upon  the  amount  and  degree  of  the  affection,  coupled 
with  the  discriminating  powers  of  the  observer  and  the  possessor. 

The  many  euphonious  Greek  coinages  should  all  be  discontinued, 
because  it  is  difficult  to  obtain  one  that  is  sufficient  to  express  the  exact 
condition  of  affairs.  If  foreign  technical  expressions  are  desired,  then  a 
newly  coined  term,  u  Hypochromatopsia,"  as  expressive  of  lowered  color 
vision,  may  be  employed,  as  being  probably  the  best  for  a  genera! 
descriptive  term  for  the  different  varieties  of  the  affection,  throughout  the 
entire  color-seeing  world.  Its  use  in  this  connection  is  legitimate  and 
proper,  if  the  word  "  Chromatopsia,"  of  similar  Greek  origin,  be  assumed 
as  its  normal  equivalent.  When  the  human  species  is  reached,  there 
should  be  a  distinctive  and  recognized  difference  employed,  and  this  may 
be  best  accomplished  by  the  addition  of  "  Anthropo"  (from  the  Greek 
root  signifying  "man")  to  each  of  the  coinages,  thus  making  two 
extremely  long  and  cumbersome  words  "  Anthropochromatopsia,"  and 
"  Hypoanthropochromatopsia,"  both  of  which  can  be  avoided  by  the 
use  of  the  far  better  English  expressions,  "  Normal  human  color-per- 

1  A  term  indicating  a  theoretical  spectrum  which  might  be  mentally  produced  by 
adding  together  and  placing  in  a  spectral  line  all  of  the  individual  natural  colors 
which  have  been  perceived  by  a  normal  color-perception  apparatus. 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  467 


ception,"  and  "  Subnormal  human  color-perception."1  The  well-known 
word  Chromatopseudopsie  is  very  old,  having  been  used  by  Sommer2  in 
1823,  and  Trichinetti3  in  1844.  In  1853,  Wilson  modified  it  into 
"  Chromatopseudopsis,"4  whilst  Noel,5  in  1857,  returned  to  the  use  of 
the  original  term.  The  very  undesirable  name  "  Daltonism"6  is  just  as 
ridiculous  and  as  inexpressive  of  its  intended  signification  as  "  Bright's 
Disease,"  "  Grave's  Disease,"  "  Pott's  Disease,"  etc.,  each  of  these  names 
not  indicating  in  any  way  a  single  point  towards  the  character  of  the 
disease,  nor  giving  an  iota  of  information  in  reference  to  the  situation  of 
the  trouble.  When  such  expressions  as  "  Achromatopsia,"  "  Color- 
Blindness,"  "  Farbenblindheit,"  "  Cecite  des  Couleurs,"  etc.7  (which 
according  to  this  theory  signify  an  absolute  loss  of  the  sensory  power  of 
the  individual  filaments  of  the  optic  nerve)8  are  employed  as  terms 
significant  of  impaired  color-vision,  they  can  be  set  down  as  improper, 
because  they  can  only  be  appropriate  in  cases  of  absolute  loss  of  power  of 
the  sensory  filament,  i.  e.,  true  blindness. 

Taking  the  healthy  human  visual  apparatus  as  a  standard,  it  may  be 
considered  to  possess  what  may  be  termed  "  normal  human  color-percep- 
tion." This  term  should  not  be  thought  to  express  perfect  color-percep- 
tion, as  it  indicates  merely  the  sum  total  of  the  average  value  of  the 
working  powers  of  the  normal  visual  sensory  nerve-tissue  of  man.  The 
moment  that  a  human  color-seeing  apparatus  has  been  found  to  be  below 
the  average — under  the  normal — then  it  can  be  said  to  possess  "  subnormal 
color-perception."  This  term  is  expressive  of  an  absolute  condition.  It 
shows  one  of  three  things — that  a  color  apparatus  has  been  imperfectly 
developed,  or  that  either  a  properly  formed  material  or  a  badly  developed 
structure  is  lowered  in  its  vitality  through  disease  or  injury.  It  does  not 
say  that  there  is  "  difficult  color-perception"  (Dyschromatopsia),9  which 

1  This  new  application  of  the  word  "  subnormal,"  which  is  an  extensively  employed 
term  in  geometry,  is  to  the  author's  mind  perfectly  legitimate  in  this  connection. 

2  "Ueber  Chromatopseudopsie,  etc.,"  Jour.  d.  Chir.  u.  Augenh.,  1823." 

3  "  Chromatopseudopsie,"  Ann.  Univer.  de  Med.,  No.  1, 1884. 

4  "  Researches  on  Color-Blindness,"  etc.,  George  Wilson,  1855. 

5  "  De  la  Chromatopseudopsie,"  These  de  Paris,  No.  203, 1857. 

6  A  term  introduced  in  1827  by  Pierre  Prevost  of  Geneva. 

7  Used  by  Brewster,  Pole,  Decoude,  Cunier,  Eichmann,  Clemens,  etc. 

8  As  has  been  explained  in  the  previous  paper,  the  sole  office  of  the  individual 
sensory  filament  of  the  optic  nerve  is  for  color-perception.  Form  is  produced  by 
different  degrees  of  coetaneous  sensory  actions  from  many  proximately  placed  optic- 
nerve  filaments,  associated  with  other  perceptions  and  conceptions,  both  previously  and 
simultaneously  obtained.  Light  to  be  seen  must  be  colored.  As  has  also  been  shown, 
pure  white  is  a  compound  color  caused  by  the  simultaneous  reflection  in  a  definite 
direction  of  any  two  pure  complementary  colors,  or  of  any  even  multiple  of  pure 
complementary  colors  from  an  impinged  natural  object ;  its  visible  expression  being 
nothing  but  the  result  of  a  compound  impression  of  color. 

9  Recently  this  term  has  been  employed  to  signify  what  has  been  termed  "  Lowered 
Color-Sense." 


468         Oliver,  A  Correlation  Theory  of  Color-perception.  [April 


only  shows  a  difficulty  in  work  or  result,  not  expressing  whether  the 
answer  is  correct  or  not.  It  does  away  with  the  faulty  expression  "  false 
color-perception"  (Pseudo-chromatopsia),  a  term  which  fails  to  give  a 
better  impression  than  a  vague  idea  of  incorrectness.  Farther,  it  accom- 
plishes more  than  the  term  "abnormal  color-perception,"1  because  even 
here,  in  this  more  accurate  expression,  the  implied  signification  is  not 
sufficiently  comprehensive  :  it  states  that  there  is  a  departure  from  normal 
color-perception,  but  fails  to  tell  whether  it  is  for  the  better  or  for  the 
worse,  and  as  the  true  condition  of  affairs  is  one  of  lowered  color-sense, 
the  term  as  written  is  inadequate. 

There  have  been  many  suggestions  as  to  the  naming  of  the  different 
varieties  of  subnormal  color-perception,  names  that  have  been  employed 
with  the  hope  of  giving  a  clue  to  the  kind  of  defect,  and  to  its  amount. 
Some  authors  have  based  their  nomenclature  upon  the  colors  seen.  Hays 
gave  five  definite  conclusions  upon  this  plan.2 

By  this  method,  Mauthner  obtains  the  following  terms.  "  Erythrochlo- 
ropsie"  (red-green  seeing),  and  "  Xanthokyanopie"  (yellow-blue  seeing).3 
Other  writers,  such  as  Wilson,4  Holmgren,5  etc.,  obtain  their  namings 
from  the  imperceptible  color  or  colors. 

Careful  analyses  of  most  of  the  proclaimed  different  kinds  of  "  color- 
blindness" have  often  made  evident  that  the  observer,  in  his  endeavors  to 
explain  certain  groupings  of  intelligently  expressed  subjective  symptoms, 
or  to  give  answer  to  almost  self-determinate  physical  changes,  has  been  so 
hampered  in  his  studies  through  wTant  of  minute  research  and  carelessness 
of  observation,  that  totally  false  and  incorrect  classifications  have  arisen 
from  inadequate  data  drawn  from  faulty  conclusions.  All  this  can  be 
avoided  through  careful  and  conscientious  study  of  clinical  facts,  and  by 
remembering  and  bringing  into  play  the  intimate  relations  of  expressed 
results  existing  between  the  correlations  of  inanimate  and  animate  physical 
forces.  Strictly,  there  cannot  be  given  any  exact  kinds  of  subnormal 
color-perception.  As  was  explained,  when  speaking  of  the  incapability 
of  obtaining  any  scientific  basis  upon  which  to  place  the  error  in  its  tota- 
lity, so  here  the  same  predicament  is  met  the  moment  that  definable 
positions  of  separation  for  the  different  amounts  of  individual  fault  are 

1  Suggested  by  Burnett,  Amer.  Jour.  Med.  Sci.,  July,  1884.  On  page  240  of  Dr. 
Wm.  C.  Henry's  biography  of  John  Dalton,  published  in  1854,  George  Wilson  uses 
the  following  words  in  connection  with  his  choice  of  the  term  "  False  Vision  of 
Colors" — "  a  term  sufficiently  general  to  include  all  the  varieties  of  abnormal  color 
vision  (italics  ours)  without  committing  its  employer  to  any  theory  as  to  their  cause." 

2  Report  of  Cases  treated  in  the  Wills  Hospital  for  the  Blind  and  Lame,  etc.  By 
Isaac  Hays,  M.D.    The  Amer.  Journ.  of  the  Med.  Sciences,  Aug.  1840. 

3  Vortraege  d.  Augenheilkunde,  1879,  Hft.  iv. 

4  Researches  on  Color-Blindness,  1855. 

5  De  la  Cecite  des  Couleurs  dans  ses  Rapports  avec  les  Chemins  de  Fer  et  la 
Marine,  1877. 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  469 

attempted.  Every  color-perception  apparatus  has  its  peculiar  amount  of 
power — even  more  ;  each  component  filament  has  its  separate  strength, 
and  what  might  be  an  error  in  one  sensory  avenue,  may  be  the  normal 
power  of  another  sensory  channel.  From  the  past  experiments,  it  is 
certain  that  those  optic  nerve  fibrils  which  terminate  externally  in  the 
macular  region  of  the  ocular  retina  are  the  ones  of  highest  physical 
and  physiological  evolution.  They  and  their  allied  extensions  represent 
the  highest  forms  of  evolutionized  machinery,  and  they  hold  the  acme 
of  sensory  life  force  destined  for  the  conversion  of  natural  color  into  cor- 
related perceptions.  As  was  also  seen,  those  optic  nerve  filaments  of  the 
most  distant  circum macular  regions  of  the  same  ocular  retina  gave  but 
minimum  results  as  compared  with  their  more  fortunately  placed  co- 
laborers  in  the  macular  regions,  showing  that  the  peripherally  situated 
fibrils  were  of  inferior  mould,  and  of  lower  sensory  life-force.  Each 
individual  optic  nerve  filament  has  a  definite  receiving  power  dependent 
upon  its  innate  physical  development  combined  with  all  that  acquired 
growth  which  has  been  the  result  of  physiological  work  and  exercise. 
How  beautifully  correlated  are  the  "  tactile  corpuscles"1  of  the  finger 
tips  to  the  optic  nerve  endings  in  the  macular  region  of  the  ocular 
retina? !  How  like  the  furthermost  limits  of  the  circummacular  regions 
of  the  ocular  retinae  are  the  feebly  responsible  tactile  terminals  of  the 
dorsal  regions  of  the  skin  !2  If  an  injury  should  happen  to  the  optic 
nerve  in  its  entire  external  spreading,  or  disease  invade  the  whole  integu- 
mentary expansion  of  the  tactile  nerves,  so  as  to  affect  their  peripheral 
distributions  equally,  both  the  subjective  and  objective  symptoms  arising 
in  the  various  situations  of  each  of  these  sensory  forms  would  depend 
upon  the  individual  physical  character  and  physiological  power  of  the  fibre 
in  the  attacked  region.  While  it  is  undoubtedly  true  that  the  symptoms 
derived  from  such  a  character  of  cause  would  be  so  totally  unlike,  and 
individually  so  differently  graded  in  seriousness  of  result,  that  no  determi- 
nate value  could  be  placed  upon  the  amount  of  the  injury  or  disease, 
by  studies  confined  to  an  individual  set  of  fibres,  yet  in  the  different  dis- 
tributions of  the  optic  nerve  fibres,  there  is  such  a  correlation  of  struc- 
ture and  power,  that  intelligent  study  of  physiological  research  to  deter- 
mine the  efficacy  of  the  normal  action  of  these  several  situations,  united 
with  proper  interpretations  of  the  visible  expressions  of  pathological 
change  taking  place  in  the  same  points,  not  only  serve  as  adequate  means 
for  finer  differential  diagnosis  in  lowered  conditions,  but  really  allow  a 
more  scientific  method  of  subnormal  color-perception  naming  than  has 
been  usually  employed. 

It  will  be  remembered,  that  whilst  speaking  of  the  production  of  subnor- 
mal color-perception,  its  presence  showed  one  of  three  things :  first,  that 

1  Gray's  Anatomy,  1862,  p.  604. 

2  Carpenter's  Principles  of  Human  Physiology,  1845,  p.  234. 


470         Oliver,  A  Correlation  Theory  of  Color-perception.  [April 


there  may  be  imperfect  development ;  second,  that  properly  formed  mate- 
rial may  be  lowered  in  its  vitality  through  injury  or  disease  ;  and  third, 
that  badly  developed  structures  may  be  damaged  by  traumatic  action  or 
pathological  change.  Therefore  these  well-marked  distinctions  demand  a 
primary  classification  of  the  general  condition  into  two  principal  heads. 
First,  a  congenital  defect  in  which  there  never  has  been  proper  working 
machinery  brought  into  the  world,  and  where  the  material  from  the  very 
commencement  of  its  life's  history  has  been  inadequate  to  the  demands 
required  of  it  by  extraneous  stimuli.  Second,  an  acquired  change  in 
which  either  a  properly  developed  structure  or  a  badly  formed  substance 
has  been  physically  damaged  by  some  accidental  occurrence  happening 
during  its  lifetime.  In  each  of  these  two  heads,  from  the  first  impair- 
ment of  visible  color  result  to  its  absolute  destruction,  there  may  be  crudely 
differentiated  five  gross  stages  of  recognizable  difference. 

First.  Where  subnormal  color-perception  is  manifested  by  an  incapa- 
bility to  respond  to  very  weak  intensities  of  the  entire  number  of  pure 
natural  colors  which  constitute  the  normal  average  power  of  the  human 
visual  apparatus  ;  this  expression  of  inability  being  more  pronounced  with 
those  beams  of  natural  colored  light  which  are  productive  of  "green." 

Second.  In  which  a  greater  intensity  of  the  pure  natural  colors  of  the 
entire  normal  average  seen  is  necessary  for  perception,  accompanied  by 
an  absolute  loss  of  response  to  those  beams  of  natural  light  which  give  rise 
to  "green"  ;  the  grading  of  necessary  natural  intensity  following  the  same 
general  law  as  in  the  first  stage. 

Third.  Where  still  greater  intensities  are  necessary  for  the  proper  re- 
cognition of  those  pure  natural  colors  which  are  as  yet  sufficiently  able  to 
call  forth  nerve  energies  for  their  perception,  this  being  associated  with 
an  inability  of  the  lowered  material  to  respond  to  those  beams  of  natural 
light  which  give  rise  to  both  "  green"  and  "  red." 

Fourth.  In  which  the  intensities  of  those  pure  natural  colors  which  are 
still  visible  must  be  further  increased,  this  condition  being  combined  with 
an  absolute  want  of  perception  of  those  beams  of  natural  light  productive 
of  "  green,"  "  red,"  and  "  blue"  ;  the  ratio  of  intensity  following  the  same 
order  as  in  the  previous  stages. 

Fifth.  In  which  the  last  remnants  of  color-perception  manifest  them- 
selves by  a  response  to  the  strongest  intensities  of  the  "  yellow"  portion  of 
the  natural  color  spectrum  ;  the  order  of  increase  of  necessary  intensity 
being  the  same  as  before. 

Although  it  would  have  been  better  mathematically  to  obtain  situa- 
tions, as  for  instance  in  the  solar  spectrum,  for  the  exact  value  of  the 
representative  natural  vibrations  giving  rise  to  the  visible  colors  known 
as  yellow,  blue,  red,  and  green,  which  would  have  thus  formed  an  estab- 
lished basis  upon  which  to  place  subnormal  color-perception,  yet  the  ex- 
isting state  of  knowledge  upon  the  subject  is  so  crude,  that  it  was  found 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception. 


471 


obligatory  to  make  these  arbitrary  stages  of  lowered  color-perception  with- 
out reference  to  what  may  have  been  considered  the  number  and  the  in- 
tensity of  natural  vibrations  chosen  for  each  typical  natural  representative 
of  such  visible  color.  This  faulty  naming  will  be  compulsory  until  na- 
tional standards  for  normal  color-perception  from  previously  agreed  upon 
natural  colors  of  definite  vibration  and  intensity  shall  be  obtained,  and  a 
series  of  international  experiments  conducted  with  the  chosen  natural 
colors,  in  order  to  find  the  average  results  of  differently  placed  and  simi- 
larly conditioned  normal  visual  apparatuses. 

The  perceptive  result  "  white,"  which  arises  from  a  compound  natural 
color  vibration,  has  been  ignored  throughout  the  definitions  of  the  various 
stages.  This  was  done  designedly.  As  will  be  illustratively  explained  in 
a  series  of  typical  figures  representing  the  various  stages  of  the  condition, 
"  white"  is  in  existence  as  long  as  its  component  natural  parts  are  sufficiently 
strong  to  produce  individual  response.  The  moment  that  the  constituent 
actions  of  "  white"  disappear,  that  moment  the  compound  result  ceases. 
In  the  series  of  experiments  conducted  to  determine  the  various  changes 
of  visible  result  undergone  by  similarly  sized  squares  of  different  colors 
whilst  they  were  being  made  to  traverse  the  more  and  more  sensitive  re- 
gions of  the  normal  ocular  retina,  the  following  result  was  obtained,  which 
bears  directly  upon  this  question,  %.  e.,  that  by  common  daylight  every 
color  tried  first  appeared  as  a  faint  gray,  then  white,  followed  by  other 
changes,  before  it  was  correctly  recognized.  This  shows  that  the  recep- 
tion of  a  compound  natural  color  and  the  reception  of  a  primary  natural 
color  are  unlike.  The  former  is  the  receiving  of  a  compound  impression 
(a  natural  stimulus  of  great  power),  which  causes  the  transmission  of  the 
entire  amount  of  nerve-energy  of  the  impinged  filament  tip,  whilst  the 
latter  is  a  more  complicated  action,  consisting  in  the  separation  of  an 
amount  of  nerve-energy  physiologically  equal  to  the  amount  of  impinging 
natural  force,  from  the  "  energy-equivalent"  resident  in  the  peripheral 
termination  of  the  impressed  nerve  fibre,  associated  with  a  transmission 
of  a  "  specific  energy"  inwards  for  perception.  The  latter  action  is 
the  more  difficult  of  the  two,  and  requires  greater  nerve  strength.  By 
stimulus  from  ordinary  solar  light  there  will  be  a  recognition  of  "  pure 
white"  throughout  the  various  stages  of  subnormal  color-perception,  just 
as  long  as  the  lowered  vitality  of  the  impinged  optic  nerve  fibril  is 
sufficiently  high  to  receive  and  transmit  for  perception  any  two  com- 
plementaries  of  the  thousands  of  complements  in  this  impure  variety  of 
compound  white  light.1  The  moment  that  either  one  of  the  contained 
complements  of  the  last  pair  of  receivable  complementaries  is  incorrectly 
recognized,  that  moment  the  last  "  pure  white"  begins  to  fade  into  ever- 
increasing  grays  until  darkness  terminates  the  scene.    Long  before  this 

1  See  Theorems  of  natural  color  in  first  paper.  . 


472         Oliver,  A  Correlation  Theory  of  Color-perception.  [April 


last  "  pure  white"  commences  to  go  through  its  dying  stages,  thousands 
of  other  "  pure  whites"  have  passed  through  relatively  similar  conditions  ; 
each  dying  in  its  turn ;  each  passing  out  of  existence  in  its  proper  rotation. 
The  series  of  increasing  grays  which  arise  after  the  death  of  the  last 
"  pure  white,"  must  result  from  a  combination  of  a  number  of  low  invisible 
intensities  of  what  would  be  "yellow"  by  heightened  intensity,  each  too 
feeble  in  its  lower  state  to  give  special  reception,  yet  sufficiently  strong 
in  combination  to  cause  sensation  and  consequent  perception.  As  each 
individual  "primary"  fades  and  dies,  so  will  the  power  of  combined  color 
disappear,  until  at  last,  when  all  have  gone,  color-perception  will  have 
ceased. 

These  stages  and  their  relations  to  the  simultaneous  and  dependent  per- 
ception "white"  can  be  graphically  described  by  the  following  figures. 

Let  Figure  1  represent  normal  color- 
pjg.;  perception  as  obtained  from  the  hu- 

man visual  apparatus  after  years  of 
^  exposure  to  those  numerous  natural 
objects  which  have  the  passive  power 
of  reflecting  varying  quantities  of 
natural  color  stimulus. 

The  heavy  ruled  base  line  a  b 
has  one  square  G  (for  "green"), 
followed  by  three  rectangles  of  in- 
^  creasing  heights  R,  b,  and  y  (for 
"red,"  "blue,"  and  "yellow") 
situated  upon  its  upper  side.  Each 
of  these  areas  is  supposed  to  contain 
a  theoretical  pile  of  narrow  color 
p  strips  of  each  of  the  above  series  of 
"  visible  color"  :  each  individual 
color  being  of  the  pure  type.1  The 
height  of  the  area  designates  the 
amount  of  pure  sensory  colors  which  constitute  the  normal  power  of  the  total 
human  visual  apparatus  for  the  perception  of  that  particular  series  of  pure 
natural  color ;  the  weaker  special  visible  colors  being  placed  in  the  upper 
portion  of  the  color  area.  The  comparative  heights  of  the  four  areas  desig- 
nate the  relative  values  of  the  numbers  of  special  colors  seen.  It  has  been 
presumed  (roughly),  for  sake  of  explanation,  that  there  are  three  times  as 
many  individual  "yellow"  perceptions  as  there  are  separate  "green"  per- 
ceptions. All  of  the  "pure  complements"  of  the  "red-green"  series,  as 
well  as  those  of  the  "  blue-yellow"  series,  are  each  supposed  to  be  on  the 


H 

I 

G 

G 

R 

B 

Y 

J 

K 

P." 

W. 

Q 

3  R  W. 

m 

R 

N 

T 

0 

1  "  Pure  type."  That  is  derived  from  a  pure  natural  color  or  primary.  Such  visible 
colors  will  be  spoken  of  as  "pure  greens,"  "  pure  reds,"  .etc.  All  sensory  colors  will 
be  placed  in  quotation  marks,  as  indicative  of  expressed  result. 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  473 

same  level.  Situated  beneath  the  base  line  A  b,  and  in  connection  with  it, 
there  is  a  duplication  of  the  entire  area  of  pure  natural  color-perceptions  : 
a  space  which  represents  the  entire  amount  of  recognized  results  which 
have  arisen  from  the  perception  of  natural  tones  and  multiple  colors  ;*  the 
number  of  the  perceptions  being  dependent  upon  the  sum  total  of  power 
that  the  visual  apparatus  has  under  command  in  the  perception  of  the 
primary  natural  colors.  The  theoretical  strips  of  "  compound  color"  in 
the  lower  space  are  presumed  to  be  wider  than  those  for  the  individual 
"  pure  colors"  in  the  upper  space,  because  in  the  former  there  is  a  stronger 
stimulus  and  a  greater  result.  Strictly,  the  entire  lower  space  should  not 
have  been  made  of  the  same  size  as  the  upper  one,  but  this  has  been  done 
with  the  intention  of  making  the  explanation  easier,  and  because  this  dis- 
crepancy does  not  affect  the  correctness  of  the  figure.  The  area  desig- 
nated as  a  e  s  k  gives  the  entire  number  of  "  pure  whites"  that  have 
been  obtained  from  the  combination  of  any  two  pure  complements  of  the 
"  pure  reds"  and  "  pure  greens"  situated  over  it,  or  from  any  even  mul- 
tiple of  such  pure  complementary  colors.  The  space  bounded  by  q  m  r  s 
holds  all  those  "  impure  whites"  and  "  impure  blacks"  (tints  and  shades2) 
which  have  been  caused  by  the  union  of  impure  complements  with  the 
remaining  "  pure  reds"  of  the  equivalent  area  above  the  base  line,  which 
have  no  "  pure  green"  complements  with  which  to  combine  in  the  forma- 
tion of  "  pure  whites."  The  area  k  n  p  b  contains  all  of  the  "  pure 
whites"  which  have  resulted  from  the  union  of  any  two  pure  complements 
or  even  multiples  of  pure  complements  of  the  "  yellow-blue"  series.  The 
small  space  beneath  this — t  o  f  p — incloses  all  of  those  "  impure  whites" 
and  "  impure  blacks"  which  have  resulted  from  the  union  of  impure  com- 
plements with  the  residual  "  pure  yellows"  of  the  equivalently  placed  area 
above  the  base  line.  The  entire  lower  area  may  also  be  considered  to 
contain  innumerable  impure  complements  which  might  arise  from  com- 
binations of  the  individual  primary  colors  in  the  upper  strips.  There- 
fore, this  figure  graphically  shows  a  theoretical  average  power  of  human 
color-perception  for  both  the  separate  and  combined  forms  of  the  many 
varieties  of  pure  natural  color,  and  serves  as  a  physiological  representative 
of  a  definite  and  comprehensible  although  uncountable  amount  of  the  total 
number  of  primary  natural  colors  which  have  been  employed  in  its  for- 
mation and  have  contributed  towards  its  functional  existence. 

Fig.  2  is  intended  to  represent  the  first  stage  of  subnormal  color- 
perception  where  there  is  an  inability  to  respond  to  the  very  weak  inten- 
sities of  the  entire  number  of  primary  natural  colors  which  constitute  the 
normal  power  of  the  visual  apparatus  ;  this  incapability  being  more  pro- 
nounced amongst  the  "  greens."  The  area  a,  which  in  Fig.  1  repre- 
sented the  total  amount  of  visible  "  pure  greens,"  is  bisected  by  a  horizontal 


1  Amer.  Jour.  Med.  Sci.,  Jan.  1885,  p.  109. 


2  Idem,  p.  110. 


474         Oliver,  A  Correlation  Theory  of  Color-perception.  [April 


line,  this  line  having  the  letter  c  at  its  extremity.  The  upper  half  of  the 
original  area  G  is  bounded  by  dotted  lines,  meaning  that  the  sensory  colors 
which  occupied  this  portion  have  been  absolutely  lost.    The  small  letters 

G,  h,  and  i,  have  each  been  made 


Fig.  2. 


H 


£ 

RW. 


R 


M 


B 


Y 


R  W. 


8 


P 


to  drop  less  and  less  distances  from 
their  previous  heights,  indicating 
that  a  less  and  less  loss  has  been  ex- 
perienced by  each  succeeding  color 
series.  So  far,  this  figure  shows 
that  there  is  a  slight  imperfection 
in  the  human  visual  apparatus  for 
the  weakest  intensities  of  the  four 
series  of  primary  natural  colors,  yel- 
low, blue,  red,  and  green.  Further, 
it  gives  the  theoretical  order  and 
amount  of  error,  and  states  which  of 
the  series  of  pure  natural  color  feels 
the  greatest  brunt.  Beneath  the 
base  line  a  b  there  is  a  duplication 
of  this  order  of  loss  of  intensity 
' '  and  vibration  of  color-perception 
intended  to  show  the  character  of 
loss  for  combined  colors.  The  original  area  a  e  s  k,  in  Fig.  1,  the  repre- 
sentative of  those  "  pure  whites"  which  resulted  from  "  green-red"  pure 
complements,  is  seen  in  this  figure  to  be  decreased  to  one-half  of  its 
former  size,  whilst  the  space  bounded  by  Q  m  r  s,  which  in  Fig.  1 
represented  the  amount  of  impure  black  and  white  results,  from  the  union 
of  impure  complements  to  the  remaining  "  pure  reds,"  has  increased  in 
extent,  although  having  been  pushed  up  towards  the  base  line  a  b.  These 
latter  changes  show  that  in  the  first  stage  of  subnormal  color-perception 
there  is  dependent  upon  the  previously-mentioned  losses  an  actual  loss  of 
one-half  of  the  average  number  of  "  pure  whites,"  which  are  normally 
derived  from  the  "  green-red"  series  of  pure  complements,  superadded  to 
a  relatively  less  diminution  (in  fact,  an  actual  gain)  in  the  numbers  of 
impure  tints  and  shades  which  result  from  the  combination  of  impure 
complements  with  the  less  weakened  "  pure  reds."  The  space  k  n  p  b, 
which  in  Fig.  1  exhibited  the  amount  of  "  pure  whites"  resulting  from 
the  "blue-yellow"  series  of  pure  complements,  is  lessened  in  area,  whilst 
the  area  t  o  f  p  has  undergone  enlargement.  The  first  of  these  varia- 
tions shows  that  there  has  been  a  loss  of  a  certain  number  of  "yellow- 
blue"  pure  whites,  although  the  relative  amount  of  disappearance  has  not 
been  so  great  as  that  amongst  the  "  pure  whites"  which  have  been  an- 
nulled by  the  failure  of  response  to  the  "  green-red"  pure  combinations. 
The  second  of  these  variations  shows  that  a  few  of  the  original  "  pure- 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception. 


475 


whites"  of  "  yellow-blue"  origin  have  become  of  the  impure  type,  and 
have  been  added  to  the  lessened  number  of  original  sensory  tints  and 
shades  which  resulted  from  the  combination  of  "pure  yellow"  with  impure 
complements. 

Fig.  3  shows  the  second  stage  in  which  a  more  intense  action  of  the 
pure  natural  colors  of  the  entire  normal  average  seen  is  necessary  for  per- 
ception ;  this  condition  being  asso- 
ciated with  an  absolute  loss  of  re- 
sponse to  those  beams  of  natural 
light  which  give  rise  to  "greens." 

Here  the  space  G  (for  the 
"  greens")  above  the  base  line  a 
b  is  wiped  out,  whilst  the  areas 
r,  b,  and  y  (for  the  "  pure  reds," 
"pure  blues,"  and  "pure  yellows") 
have  each  been  lowered  in  decreas- 
ing quantity.  Besides  graphically 
illustrating  the  ratios  of  change  as 
expressed  by  the  remaining  amounts 
of  the  different  colors,  these  varia- 
tions indicate  that  the  visual  appa- 
ratus has  either  undergone  further 
pathological  alteration  of  a  definite 
character,  or  that  there  is  a  greater 
defect  in  the  primary  development 
of  the  mechanism  than  it  was  supposed  to  have  in  the  first  stage.  Per- 
ception of  "  green"  has  been  annihilated;  perception  of  "red"  is  limited 
to  less  than  one-half  of  its  original  amount ;  perception  of  "blue"  and  of 
"yellow"  are  both  cut  down  in  unequal  proportions;  that  for  "yellow" 
being  the  less  damaged.  In  the  equivalently  sized  general  space  under 
the  base  line  a  b,  there  have  arisen  several  modifications.  The  narrow 
area  a  e  s  k,  of  Fig.  2,  representing  the  amount  of  decrease  in  the  num- 
ber of  "  green-red"  "  pure  whites,"  which  resulted  from  the  remaining 
number  of  "  green-red"  pure  complementaries,  is  entirely  wanting  in  this 
figure,  showing  that  in  this  lower  condition  there  are  no  "  green-red" 
"  pure  whites."  Two-thirds  of  the  area  entitled  q  m  r  s,  which  in  Fig. 
2  represented  the  number  of  impure  complements  that  might  arise  from 
the  union  of  some  remaining  "  pure  reds"  with  any  other  existing  sensory 
color  or  colors,  are  abolished.  The  remaining  third  has  had  added  to  it 
the  remaining  unimpaired  "  pure  reds,"  which  of  themselves  might  have 
continued  to  give  rise  to  the  series  of  "  green-red"  "  pure  whites,"  seen  in 
Fig.  2,  if  the  "  pure  greens"  had  not  been  lost,  but  now,  upon  account  of 
the  destruction  of  the  "  pure  greens,"  the  still  large  area  J  m  r  k  is 
limited  to  the  perception  of  the  union  of  the  contained  "  pure  reds"  with 


476         Oliver,  A  Correlation  Theory  of  Color-perception.  [April 


Fier.  4. 


1 


impure  complements.  The  space  k  n  p  b  in  the  lower  part  of  Fig.  3 
has  decreased  in  area,  showing  that  the  number  of  "  yellow-blue"  "  pure 
whites"  has  diminished,  whilst  the  area  t  o  f  p  occupies  a  larger  extent, 
this  latter  change  illustrating  how  the  number  of  "  impure  whites"  and 
"  impure  blacks"  derivable  from  the  "yellow"  series  of  impure  comple- 
ments has  increased,  even  though  there  has  been  an  extra  percentage  of 
lost  "  yellows." 

Fig.  4  shows  the  third  stage,  where  still  greater  intensities  are  neces- 
sary for  the  proper  recognition  of  those  pure  natural  colors  which  are  as 

yet  able  to  call  forth  nerve  energies 
for  their  perception,  this  being  asso- 
sociated  with  an  inability  of  the 
lowered  material  to  respond  to  those 
beams  of  natural  light  which  give 
rise  to  both  "  greens"  and  "  reds." 
The  space  r  above  the  base  line 
a  b,  in  Fig.  3,  has  now  disappeared, 
showing  that  all  perception  for  the 
"  pure  red"  has  ceased.  Both  of  the 
areas,  b  (for  the  "  pure  blues")  and 
y  (for  the  "  pure  yellows")  are  still 
further  lowered  than  they  were  in 
the  previous  figure,  this  being  less 
marked  for  the  latter  series  of  in- 
dividual sensory  colors.  Beneath 
i  j        the  base  line  A  b,  the  space  in  Fig. 

,  i        g  occupied  by  those  tints  and  shades 

of  "red"  which  were  still  visible, 
is  lost  in  this  figure.  Perception  of  combined  color  is  limited  to  a  lessened 
number  (k  n  p  b)  of  "  yellow-blue"  "  pure  whites"  than  heretofore,  asso- 
ciated with  an  increased  amount  (t  o  f  p)  of  "  impure  whites"  and 
"  impure  blacks,"  which  result  from  the  now  greater  number  of  "yellow- 
blue"  "  impure  complements." 

Fig.  5  represents  the  fourth  stage,  in  which  the  intensities  of  those  pure 
natural  colors  which  are  still  visible  must  be  further  increased,  this  con- 
dition being  combined  with  an  absolute  want  of  perception  of  those  beams 
of  natural  light  which  are  productive  of  "  greens,"  "  reds,"  and  "  blues." 
In  this  figure  the  space  above  the  base  line  A  b,  which  was  occupied  by 
the  area  R  in  Fig.  4,  is  annihilated,  which  indicates  that  there  are  no 
"  blue"  perceptions.  The  area  y  is  lessened  in  height,  which  shows  that 
there  has  been  a  further  loss  in  the  number  of  "  pure  yellows."  Below 
the  base  line  a  b,  the  space  which  in  Fig.  4  constituted  the  area  k  n  p  b, 
and  which  represented  the  amount  of  remaining  "  blue-yellow"  "  pure 
whites,"  is  pressed  out  of  existence.    In  fact,  below  the  base  line  there  is 


'  H 

B 

Y 

N 

RTW. 

1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  477 


nothing  but  an  area  l  o  f  b  which  indicates  the  amount  of  "  tints"  and 
"  shades"  that  might  arise  through  the  combination  of  the  different  inten- 
sities of  the  still  existent  "  pure  yellow"  series. 


Fig.  6  furnishes  a  graphic  description  of  the  condition  in  which  the 
last  remnants  of  color-perception  manifest  themselves  by  responses  to  the 
strongest  intensities  alone  of  the  "  yellow"  portions  of  the  natural  color 
spectrum.  The  triangular  space  l  d  b  above  the  base  line  a  b  gives  the 
amount  of  visible  yellow  primaries.  It  holds  the  highest  intensities  of 
"  pure  yellow"  perceptions;  it  shows  the  dying  stages  of  subnormal  color 
perception,  and  represents  the  last  individual  color  to  go.  The  duplicate 
space  beneath  the  base  line  contains  all  of  the  compound  sensory  colors 
which  might  result  from  the  union  of  the  "pure  yellows"  situated  in  the 
upper  space.  These  combinations  in  the  lower  area  must  be  of  the  impure 
variety,  and  consist  of  gradually  increasing  "  shades."1  As  the  upper 
triangle  disappears,  so  does  its  fellow  beneath,  until  at  last,  when  all  above 
the  base  line  has  gone,  the  lower  area  will  have  ceased  to  exist,  and  color- 
perception  be  lost. 

For  convenience  of  study  and  for  a  desire  to  give  an  exact  locality 
for  the  causative  fault  or  change,  these  five  stages  of  subnormal  color- 
perception  have  been  assumed  to  take  place  in  a  series  of  differently  de- 
fined positions  of  two  distinct  and  separate  situations.  The  first  of  these 
principal  situations  is  supposed  to  be  the  entire  length  of  the  sensific  part 
of  one  of  the  optic  nerve  filaments,  whilst  the  second  situation  is  supposed 


1  They  are  compounds,  and  belong  to  the  variety  designated  as  "impure  whites." 
No.  CLXXVIII  April,  1885.  31 


478         Oliver,  A  Correlation  Theory  of  Color-perception.  [April 


to  be  the  entire  length  of  the  related  perceptive  tract.  After  the  estab- 
lishment of  these  two  general  positions,  it  becomes  necessary  to  give 
more  exact  seats  for  the  resident  fault  or  error.  This  can  be  best 
accomplished  by  dividing  the  visual  apparatus  into  its  three  originally 
used  divisions — the  receiving  or  ocular  retina,  the  transmitting  fibre, 
and  the  discharging  or  cerebral  retina, — and  then  separating  the  related 
perceptive  elements  into  their  three  parts — the  low  perceptive  cell,  the  con- 
veying fibre,  and  the  high  perceiving  cell ; — after  which  he  may  presume 
that  each  and  every  responding  nerve  fibre,  from  its  peripheral  extremity 
to  its  most  internal  reaching,  has  such  separations,  and  that  each  individual 
nerve  is  liable  to  the  formation  of  a  fault,  or  to  the  rise  of  an  error  in 
any  such  portion  of  these  two  principal  situations,  throughout  the  entire 
length.  Whilst  thus  far  this  classification  enables  a  determinate  resi- 
dency to  be  given  to  any  imperfection,  yet  it  utterly  fails  to  specify  the 
exact  spot  of  the  trouble  in  any  such  position.  The  same  difficulty  as 
was  spoken  of  during  the  discussion  of  the  experiments  to  determine  the 
comparative  physiological  powers  of  the  nerve  structures  in  the  macular 
region  and  circummacular  region  of  the  ocular  retina  presents  itself  here. 
It  will  be  remembered  that  no  sharp  line  could  be  drawn  between  the  two 
places,  because  of  the  gradual  decrease  of  the  expressed  powers.  It 
will  be  also  recollected  that  most  of  the  physiological  investigations  were 
conducted  with  the  fibres  of  the  furthermost  limits  of  the  generally-used 
portion  of  the  ocular  retina,  in  contradistinction  to  the  fibres  of  direct 
use;  this  being  done,  in  order  to  have  a  comparison  between  the  weakest 
and  the  strongest  filaments  which  contain  employed  nerve  force.  It  will 
be  further  remembered  that  the  same  nerve  fibre  w^as  presumed  to  pursue 
an  uninterrupted  course  inwards.  Consequently,  it  has  been  thought 
advisable  to  have  the  nerve  fibre,  which  has  its  peripheral  termination  in 
the  macular  region  of  the  ocular  retina  differentiated  from  the  nerve  fibre, 
which  has  its  receiving  tip  placed  in  the  circummacular  region  of  the 
ocular  retina ;  this  distinction  remaining  separate  and  unattached  in  any 
way  throughout  all  the  post  and  stations  encountered  in  the  entire  length 
of  the  two  fibrils.  These  various  positions  can  be  illustrated  best  by  the 
following  scheme. 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  479 


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480         Oliver,  A  Correlation  Theory  of  Color-perception.  [April 


By  the  use  of  this  scheme,  the  exact  position  of  any  character  of  de- 
finable error  can  be  "gotten  at  a  moment's  glance ;  for  instance,  a  con- 
genital subnormal  color-perception  of  the  second  stage,  dependent  upon  a 
fault  in  the  transmitting  part  of  the  sensory  portion  of  a  macular  filament, 
can  be  readily  differentiated  from  an  acquired  subnormal  color-perception 
of  the  third  stage  which  has  resulted  from  some  change  having  taken 
place  in  the  receiving  cell  of  the  sensory  portion  of  a  circummacular 
filament.1 

Resume. — Throughout  the  entire  animal  existence,  each  individual 
nerve  fibre  is  supposed  to  be  similar  in  its  physical  construction  and  phy- 
siological action^  although  each  fibre  has  its  idiocratic  ratio  of  structural 
substance  and  value  of  working  force,  which  peculiarity  of  constitution 
and  difference  of  susceptibility  to  extraneous  impression  gives  the  element 
its  representative  distinction.  Each  individual  structure  of  the  so-called 
"five  senses"  in  the  human  being  has  a  receiving  tip,  a  transmitting  por- 
tion, and  a  discharging  terminus.  Each  receiving  tip  is  put  in  such  a 
position  as  to  be  able  to  change  impinging  natural  impressions  of  its  kind 
into  equivalent  nerve-energies.  Each  connecting  link  carries  these  ener- 
gies inwards  to  the  discharging  cell.  Each  internal  discharging  sensory 
cell,  which  is  either  in  a  direct  or  in  an  indirect,  though  intimate  relation 
with  some  definite  perceptive  element,  causes  a  complete  evolution  of  the 
sensation.  The  fully  evolved  sensation  is  transformed  into  a  correspond- 
ing and  relatively  low  perception,  by  certain  cells,  of  related  mental  growth 
and  power.  The  evanescent  perception,  if  of  sufficient  strength,  is  still  fur- 
ther evolved  into  a  higher  intelligent  perception,  either  by  the  deposition  of 
a  new  cerebral  cortex-cell  of  representative  value  in  the  higher  mental  cen- 
tres, or  by  a  restamping  of  some  already  formed  and  reciprocal  cell  in  such  a 
position  ;  the  first  act  constituting  an  automatic  perception  of  the  sensa- 
tion, the  second  an  intelligent  perception.  This  is  the  completed  mecha- 
nical action  of  a  sensory  nerve  where  the  mentality  is  called  into  play, 
and  should  not  be  confounded  with  those  manifestations  of  motor  impulses 
which  result  from  a  lower  grade  of  sensory  action.  In  every  living 
organism  there  is  a  system  of  afferent  nerve  structures,  which  are  in  con- 
nection with  the  great  ganglionic  centres,  and  it  is  in  the  gray  matter  of 
these  situations  that  the  sensory-motor  combinations  are  effected.  If  the 
sensory-motor  nerves  be  of  low  type,  and  if  the  central  ganglion  does  not 

1  These  two  theoretical  examples  might  be  multiplied  indefinitely,  and  cases  cited 
in  support  of  the  various  types,  hut  for  explanation  they  are  deemed  sufficient.  The 
results  of  other  studies  in  subnormal  color-perception  are  being  reserved  for  other 
papers,  in  which  such  topics  as  the  question  of  its  effects  upon  "subjective  after 
colors,"  and  "  subjective  colors  its  manifestation  upon  mathematically  obtained 
relative  intensities  of  pure  natural  color  ;  its  value  in  the  diagnosis  and  localization  of 
pathological  change  ;  its  use  in  indicating  the  severity  of  causal  disease  ;  its  worth  as 
a  prognostic  factor ;  and  its  service  in  the  further  study  of  normal  action,  will  all  be 
considered. 


1885.]     Oliver,  A  Correlation  Theory  of  Color-perception.  481 


possess  mental  activity,  as  in  the  variously  placed  human  nerve  plexuses 
which  control  involuntary  organic  action,  the  sensation,  instead  of  termi- 
nating in  perception,  gives  rise  to  another  and  lower  form  of  organic 
motion.  Here  there  is  no  perception  of  the  action.  In  each  of  the 
human  viscera,  there  are  variously  graded  life  powers,  such  as  are  so 
often  seen  constituting  the  total  nerve  force  of  many  of  the  lowest  forms 
of  animation ;  both  being  mere  involuntary  living  mechanisms  acting 
identically  in  one  determinate  way,  no  matter  what  the  nature  of  the 
stimulus  may  be.  Curiously,  the  human  viscera  have  coupled  with  their 
separate  acts  some  connective  link  with  the  brain,  as  has  been  frequently 
shown  by  the  consequences  of  profound  mental  disturbances  upon  vis- 
ceral excretion  and  secretion.  This  is  probably  due  to  an  ascent  in  the 
scale  of  evolutionized  material.  Nevertheless,  it  is  certain  that  the 
human  stomach,  intestines,  liver,  kidneys,  etc.,  each  may  be  set  into  its 
peculiar  variety  of  life  motion  by  many  stimulating  agencies  that  have  been 
able  to  find  access  to  its  sensory  elements,  even  though  the  foreign 
substance  should  either  not  be  acted  upon  at  all,  or  its  very  presence 
should  occasion  injurious  result  upon  the  organ.  As  the  human  viscera 
are  bound  together  by  a  chain  of  ganglia  connected  b}^  intervening  cords 
termed  the  "  sympathetic  system,"  so  the  more  highly  developed,  though 
correlated  human  sensory  organs  and  voluntary  motor  apparatuses  are 
united  in  a  ganglionic  centre  entitled  the  "  cerebro-spinal  axis,"  the  lat- 
ter being  the  finer  material,  and  capable  of  better  results.  In  that  won- 
derful complexity  of  human  nerve  material,  designated  as  "  the  brain," 
which  constitutes  the  most  highly  developed  part  of  the  cerebro-spinal 
system,  there  is  brought  into  play,  as  the  result  of  the  highest  character  of 
physiological  action  of  the  combined  higher  sensory  and  motor  impulses, 
a  new  existence,  a  governing  agent,  a  mentality,  an  intelligence,  a  will, 
an  emotion.  In  this  position  there  has  been  "  a  something  more"  added 
to  the  mere  sensation.  There  is  a,  perception  of  the  sensory  result;  there 
is  a  cognizance  of  a  sensory  action.  To  this  class  of  bettered  sensory 
actors  belongs  the  color  apparatus.  To  this  highest  ganglionic  centre  the 
visual  channel  makes  its  way.  Its  individual  perceptions  are  of  color 
alone,  because  to  this  character  of  natural  vibration  its  material  is  fitted 
to  respond.  Each  optic  nerve  fibre  brings  thousands  of  transformed  natu- 
ral beams  of  colored  light  (equivalent  nerve  energies)  into  juxtaposition, 
with  a  related  perceptive  cell  (causing  color-perception),  which  perceptive 
acts  are  still  further  evolved  into  higher  mental  results  by  actions  and 
reactions  upon  other  life  substances,  contained  within  this  ganglionic  mass, 
thus  producing  higher  mental  answers  of  innumerable  kinds  and  char- 
acters; one  of  the  lowest  of  these  productions  being  what  is  termed  "sight." 
The  peripheral  termination  of  the  visual  apparatus  consists  of  a  surface  of 
sensory  material  placed  at  the  focusing  point  of  a  compound  system  of 
boxed  lenses  of  changeable  power ;  this  arrangement  being  made  for  the 


482 


Hinsdale,  Pernicious  Anaemia. 


[April 


correct  impingement  of  natural  color  rays.  This  portion  of  the  organ  is 
relatively  similar  to  the  so-called  skin,  and  in  fact  the  sensory  portion  ot 
it,  in  its  comparative  development,  is  nothing  more  nor  less  than  a  bundle 
of  highly  developed  tactile  corpuscles.  The  transmitting  portion  of  the 
optic  nerve  has  its  analogue  in  the  total  number  of  afferent  tactile  nerves, 
which,  in  the  visual  apparatus,  have  been  gathered  together  into  a  sheathed 
bundle  so  as  to  be  enabled  to  pass  en  masse  through  a  small  foramen 
to  the  central  ganglion.  The  cerebral  retina  is  the  compound  area  of 
cell  termination  of  the  optic  nerve,  in  connection  with  the  related  low 
perceptive  cells  of  evanescent  power,  and  has  its  equivalent  in  the  series 
of  cerebral  sensory  areas  devoted  to  the  proper  physiological  evolution  of 
the  sensations  which  give  rise  to  the  primary  perceptions  of  taction.1  Just 
as  there  has  been  an  evolution  of  organic  form  through  physiological  ac- 
tion and  the  transmission  of  bettered  material  from  parent  to  offspring,  so 
there  have  been  increases  in  certain  parts  of  the  individual  organism. 
This  is  seen  in  the  differences  of  the  actions  of  the  sensory  nerve  fibres 
in  the  macular  and  circummacular  regions  of  the  same  ocular  retina,  and 
serves  as  a  reply  to  the  question  why  certain  elements  of  the  human  ocu- 
lar retina  have  better  powers  of  receipt  than  others  in  the  same  membra- 
nous coat.  As  the  receiving  tip  of  the  individual  filament  is  different  in 
grade  of  substance  and  ability  of  action,  so  its  internal  prolongations 
must  differ  in  physical  constitution  and  physiological  worth.  These  dif- 
ferences of  organic  construction  and  sensory  power,  associated  with 
changes  in  intensity  and  number  of  natural  color  vibrations,  give  solution 
to  the  whole  problem  of  color-perception,  and  answer  the  long  asked  and 
vexed  question — How  is  natural  color  perceived  ? 
1507  Locust  Street,  Philadelphia. 


Article  XIV. 

A  Case  of  Pernicious  Anaemia;  Recovery.    By  Guy  Hinsdale,  M.D., 

of  Philadelphia. 

The  following  case,  which  was  under  treatment  at  the  Episcopal  Hos- 
pital, Philadelphia,  is  of  such  an  interesting  character,  and  terminated  so 
successfully,  that  it  is  deemed  worthy  of  being  placed  on  record. 

Theo.  J.,  set.  22,  a  bartender,  was  admitted  to  the  wards  of  that  insti- 
tution September  20,  1882,  under  the  care  of  Dr.  Morris  J.  Lewis.  For 
the  past  three  or  four  years  he  had  been  in  the  habit  of  drinking  wine, 
gin,  and  whiskey  freely,  and  of  using  tobacco.    He  had  been  taking  from 

1  These  positions  have  been  compared  with  supposed  similar  ones  for  taction.  This 
could  have  been  done  with  the  other  senses. 


1885.] 


Hinsdale,  Pernicious  Anaemia. 


483 


fifteen  to  twenty-five  drinks  a  day,'  and  he  said  that  the  whiskey  he  drank 
might  be  reckoned  at  half  a  pint  daily.  He  denied  having  had  any  vene- 
real disease  or  its  symptoms,  although  he  had  frequently  been  exposed  to 
contagion.    His  parents  had  died  in  his  infancy. 

The  patient's  previous  health  had  been  good,  and  he  stated  that  he  had 
never  had  four  days'  illness  in  his  life.  He  never  worked  in  phosphorus, 
metals,  or  paints.  He  was  of  good  color  until  his  present  attack,  which 
commenced  two  weeks  previous  to  admission.  He  was  not  thin  ;  a  fair 
amount  of  subcutaneous  fat  was  present.  Having  been  costive  for  some 
time  past,  he  began  to  have  a  dull,  continuous  pain  in  the  back  of  the  head, 
which  was  augmented  by  exertion.  For  seven  or  eight  days  his  conjunc- 
tiva had  been  yellow  ;  a  little  later  his  skin  was  tinged  with  yellow,  but 
upon  admission  had  more  of  a  waxy-white  color.  Three  days  previous  to 
admission  he  had  anorexia,  followed  by  a  chill  at  night  with  vomiting. 
His  tongue  was  pale  and  covered  with  a  white  coat.  No  symptoms  of 
dyspepsia  ;  bowels  never  loose.    Mucous  membranes  pale. 

The  patient's  spleen  was  slightly  enlarged  in  the  vertical  line.  Its  area 
of  dulness  measured  4x4  inches.  The  area  of  liver  dulness  began 
anteriorly  at  the  sixth  rib,  and  extended  to  the  margin  of  the  ribs,  but  not 
below.  The  superficial  veins  of  the  arms  were  small  and  of  a  slightly 
pink  color.  There  was  no  lymphatic  enlargement  perceptible,  and  no  pain 
on  pressure  over  the  bones.  Fluid  was  noticed  in  the  abdominal  cavity  a 
few  days  after  admission. 

The  heart  was  rapid  (120)  ;  pulse  small,  but  regular.  The  apex  beat 
was  at  the  fifth  interspace,  1.5  inches  within  the  nipple  line,  and  was  quite 
forcible.  There  was  a  soft,  long,  systolic  murmur  over  the  pulmonary 
artery,  and  a  loud  venous  hum  in  the  neck  on  sitting  up.  There  was  no 
oedema  ;  neither  had  there  been  any  hemorrhages,  nor  were  there  any 
petechias. 

The  blood  was  examined  by  Dr.  F.  P.  Henry,  one  of  the  attending  phy- 
sicians of  the  hospital,  who  reported,  October  1st,  985,000,  and  November 
1st,  1882,  890,000  red  corpuscles  to  the  cu.  mm.,  one-fifth  of  the  normal 
•number.  White  cells  numbered  one  to  two  hundred  red,  absolutely  but 
not  relatively  diminished. 

The  urine  was  slightly  acid ;  sp.  gr.  1.015.  No  albumen  was  found 
after  several  examinations.  Five  days  after  admission,  tests  showed  the 
presence  of  bile. 

The  following  is  a  record  of  the  temperature  : — 


M. 

E. 

M. 

E. 

M. 

E. 

20  ... 

101 

Oct.  8  ... 

..  100 

100.4 

Oct.  17  ... 

,  99 

100 

30  ... 

..  102.4 

100 

9  , 

..  99 

100.8 

18 

99.5 

100 

1  ... 

...  99 

99.4 

10  ... 

..  100 

100 

19  .. 

..  99.5 

99.5 

2  ... 

...  98.2 

99.2 

11  ,., 

..  100 

100.4 

20  ,  , 

..  99 

99.5 

3  ... 

..,  99 

100.1 

12 

^98.8 

100 

21  .  . 

...  99 

99 

4  ... 

...  98.5 

100 

13  ... 

..  98.8 

98.9 

22  ... 

...  99 

98.5 

5  ... 

...  98 

100.5 

14  ... 

...  98.5 

100 

23 

98.5 

6  ... 

...  99.6 

100.5 

15  ... 

...  100 

100.5 

24 

...  98 

7  ... 

...  98.5 

101 

16  ... 

...  99 

100 

The  pulse  at  first  remained  rather  high — 110  to  130. 

The  journal  shows  that,  after  the  first  few  days,  excepting  his  pain  in 
the  back  of  the  head,  he  complained  of  no  bad  feeling,  and  only  occasion- 
ally felt  weak  and  liable  to  faint.  By  the  end  of  the  first  month  the  color 
of  his  face  and  lips  improved.  His  veins  filled  up,  and  the  blood  became 
richer  and  the  man  stronger.  After  seven  weeks  of  treatment  he  was  dis- 
charged. 


484 


Hinsdale,  Pernicious  Anaemia. 


[April 


The  treatment  from  the  start  was  arsenic,  in  Fowler's  solution,  and 
afterwards  arsenious  acid  in  pill,  with  iron.  Cod-liver  oil  was  added 
after  the  first  week,  and  quinia  and  tincture  of  iron  after  the  second. 
The  patient's  diet  was  liberal,  and  consisted  of  milk,  mutton,  chicken, 
eggs,  etc. 

Dr.  Albert  G.  Heyl,  one  of  the  ophthalmic  surgeons  of  the  hospital,  has 
furnished  the  following  notes  : — 

"  Oct.  8,  1882.  E.  E.  Media  cloudy.  Margin  of  the  disk  obscured 
below.  Retinal  arteries,  if  of  abnormal  calibre,  somewhat  increased  as 
regards  diameter.  The  retinal  veins  were  tortuous,  apparently  flattened, 
and  about  double  the  normal  calibre.  A  number  of  circular  hemorrhages 
with  white  centres  were  observed  ;  most  of  them  were  contiguous  to  large 
vessels,  probably  lying  underneath  them  in  the  deeper  layers  of  the  retina. 
L.  E.  The  condition  was  much  less  marked  than  in  the  R.  E. 

ul%th.  The  principal  change  observed  was  in  the  hemorrhages.  In 
some  the  red  coloring  matter  had  been  completely  absorbed,  leaving  be- 
hind oval  or  circular  white  spots.  In  others  the  absorption  was  not  com- 
plete, and  then  the  patches  were  speckled  with  red  points.  This  seems  to 
show  that,  in  certain  abnormal  states  of  the  blood,  retinal  hemorrhages 
may  lose  the  red  coloring  matter  before  the  remainder  of  the  clot  is  ab- 
sorbed. 

"A  few  days  later  the  case  was  examined  by  reflecting  sunlight  into  the 
eyes.  Some  fresh  hemorrhages  were  observed.  Also  the  optic  disk  and 
fundus  were  of  a  yellow  hue,  due,  perhaps,  to  the  hgematin  which  had 
escaped  into  the  tissues.    The  conjunctiva  was  also  noted  as  being  yellow. 

"  The  patient  then  passed  from  observation  until  July  30,  1884.  The 
result  of  the  examination  at  this  date  was  as  follows :  R.  E.  V.=  t2q0^. 
Probably  with  cylindrical  correction  the  vision  would  have  been  greater, 
as  the  refraction  was  astigmatic. 

«L.  E.  V  =  }J. 

"  In  the  R.  E.  the  margin  of  the  optic  disk  was  distinct.  All  over  the 
fundus  the  fine  arterioles  and  venules  were  visible,  due  to  the  abnormal 
injection.  In  the  upper  half  of  the  fundus  the  main  veins  were  enlarged. 
In  the  lower  half  the  following  observations  were  made. 

"  (a)  The  main  artery  seemed  to  alter  its  calibre — sometimes  to  become 
thinner,  then  of  normal  calibre,  (b)  If  the  observer's  eye  be  directed  so 
that  the  line  of  sight  falls  in  the  vertical  plane  passing  through  the  vessel, 
it  appears  well  defined;  if  it  be  viewed  in  a  slanting  direction,  it  is  very 
dim,  and  with  difficulty  differentiated  from  the  retinal  tissue.  This  may, 
in  a  measure,  be  due  to  the  direction  given  to  the  ophthalmoscope,  but 
principally  is  caused  by  some  abnormality  in  the  blood  current,  (c)  One 
or  two  pulsatile  movements  were  noticed  in  the  vessel  on  the  retina ;  they 
could  not  be  compared  with  the  radial  pulse,  (d)  From  the  main  artery 
a  branch  was  given  off,  of  an  apparent  calibre  of  1  mm.  ;  it  rapidly 
diminished  to  a  point,  and  for  the  remainder  of  its  course  appeared  as  a 
fine  thread-like  vessel ;  following  its  course  was  a  vein  of  similar  thread- 
like calibre.  Just  before  its  junction  with  a  large  vein  the  current  lost  its 
continuity,  appearing  as  red  points  separated  by  white  interspaces.  There 
was  a  general  haziness  over  the  fundus,  probably  due  to  retinal  clouding. 
In  the  L.  E.  the  veins  were  generally  hypersemic.  An  arterial  branch 
with  a  conical  beginning  and  thread-like  continuation  leading  to  a  spot 
characterized  by  pigmentary  changes  was  likewise  observed. 


1885.] 


Hinsdale,  Pernicious  Anaemia. 


485 


"  These  late  changes  are  unknown,  I  believe,  in  connection  with  per- 
nicious anaemia,  and  point  probably  to  a  defective  state  of  the  intima  of 
the  vessels,  dating  back  to  the  acute  stage  of  the  dyscrasia." 

I  have  taken  the  trouble  to  hunt  up  this  man,  and  now,  over  two  years 
from  the  date  of  his  discharge  from  the  hospital,  I  find  him  fully  restored 
to  health.  He  weighs  over  one  hundred  and  sixty  pounds — a  gain  of 
twenty- five  pounds  since  leaving  the  ward.  Dr.  Henry  kindly  examined 
the  blood  again,  and  reported,  July  31,  1884,  "  4,500,000  red  corpuscles  to 
the  cubic  mm.  No  white  corpuscles  in  the  specimen  examined.  The 
blood  may  therefore  be  considered  of  the  normal  standard.  The  blood 
flowed  freely  on  moderate  puncture  of  the  finger,  affording  a  marked 
contrast  to  that  obtained  two  years  ago,  when  more  than  one  deep  punc- 
ture had  to  be  made  before  a  drop  could  be  obtained." 

The  ophthalmoscopic  examination  has  been  given  in  Dr.  Heyl's  report. 
The  man  is  in  full  bodily  vigor.  On  listening  to  his  heart,  the  murmur 
present  during  his  illness  is  not  heard,  but  the  first  sound  may  be  said  to 
be  muffled.  The  second  sound  is  distinct.  The  lungs  are  clear.  The 
liver  and  spleen  are  both  enlarged.  The  man  still  drinks  beer,  but  con- 
siders himself  temperate. 

The  descriptions  by  Drs.  Sidney  Coupland,1  Stephen  Mackenzie,2  Pye- 
Smith,3  Pepper,4  Lepine,5  and  Gardner  and  Osier6  should  certainly  be 
read  by  any  one  interested  in  the  study  of  this  disease.  Pye-Smith  says 
that  the  diagnosis  can  never  be  considered  absolutely  certain  during  the 
patient's  life ;  but  he  believes  that  occasionally  recovery  has  taken  place 
beyond  reasonable  doubt,  and  mentions,  in  a  list  of  122  cases  of  the 
disease,  20  cases  of  recovery,  which  he  believes  to  be  well  substantiated. 
He  describes  one  case  which  was  under  observation,  however,  for  only  one 
year  after  apparent  recovery,  but  in  which  no  blood  count  was  made ;  also 
another  case,  forming  the  subject  of  his  article,  which,  after  being  dis- 
charged from  Guy's  Hospital,  improved,  was  re-admitted,  and  died  four- 
teen months  from  the  commencement  of  treatment ;  another,  in  which  the 
count  fell  to  1,100,000,  then  to  425,000,  recovered,  the  final  numeration 
being  nearly  five  million  corpuscles  in  the  cubic  mm. 

A  case  of  pernicious  anaemia,7  which  was  under  the  care  of  Drs.  J.  H. 
Hutchinson  and  Morris  J.  Lewis,  in  the  Pennsylvania  Hospital,  was 
discharged  apparently  well  (no  blood  count  was  made),  and  he  was  able 
to  return  to  his  work  as  a  coal-miner  ;  ten  months  later  he  was  re-admitted 
to  the  hospital  with  the  same  symptoms,  and,  I  am  informed,  died  of  the 
disease.    Dr.  Hutchinson  has  also  seen  a  second  case  of  fatal  remission  in 

1  Coupland.    Gulstonian  Lectures.    Lon.  Lancet,  1881,  vol.  i. 

2  Mackenzie.    Lon.  Lancet,  1878,  vol.  ii. 

3  Pye-Smith.    Guy's  Hospital  Reports,  1883. 

*  Pepper.    Amer.  Jour.  Med.  Sciences,  Oct.  1875. 

5  Lepine.    Rev.  Mens,  de  Med.  et  Chirurg.  1877,  p.  63. 

6  Gardner  and  Osier.    Canada  Med.  and  Surg.  Jour.  1877,  p.  385. 

7  Medical  News.    Philadelphia,  February,  1879. 


486  Sattler,  One-sided  Transitory  Exophthalmos.  [April 

pernicious  anasmia.  Such  occurrences  have  been  recorded  by  Habershon,1 
"Wilks,2  and  Lepine.3 

As  for  retinal  hemorrhages,  Coupland  states  that  they  do  not  imply  a 
fatal  termination  ;  and,  on  the  other  hand,  their  absence  does  not  neces- 
sitate a  favorable  prognosis.  Quincke  found  no  retinal  hemorrhages  in 
9  out  of  39  cases. 

Pernicious  anasmia  is  therefore  not  necessarily  a  progressive  disease. 
The  fact  that  these  patients  sometimes  temporarily  regain  their  health 
has  doubtless  tempted  some  to  believe  that  a  cure  has  been  effected,  while, 
on  the  other  hand,  the  absolutely  hopeless  view  of  the  affection  entertained 
by  most  writers  has  doubtless  led  others  to  doubt  the  accuracy  of  their 
diagnosis  had  they  called  it  progressive  pernicious  anosmia. 

The  records  of  the  case  which  I  have  furnished,  extending  over  more 
than  two  years,  and  terminating  in  a  normal  blood  count,  and  full  bodily 
vigor,  add  one  more  to  the  list  of  cases  which  justify  us  in  having  a  slightly 
more  hopeful  view  even  of  so  dangerous  a  malady  as  pernicious  anasmia. 

4004  Chestnut  St.,  Philadelphia. 


Article  XV. 

A  Case  of  One-sided  Transitory  Exophthalmos,  with  Undisturbed 
Function  and  Muscular  Movements  of  the  Eye  and  the  Coex- 
istence of  Exophthalmos  or  Recession  of  the  Globe.  By  Robert 
Sattler,  M.D.,  Ophthalmic  Surgeon  to  Cincinnati  Hospital,  etc. 

Exophthalmos,  or  displacement  of  the  eyeball,  constitutes  a  constant 
and  characteristic  symptom  of  the  diseases  of  the  orbit  attended  by 
inflammatory  exudation,  also  of  tumors,  cysts,  etc.,  and  of  traumatic 
lesions,  accompanied  by  hemorrhagic  extravasation.  In  another  rare 
class  of  cases,  it  is  equally  constant  and  conspicuous — rupture  of  the 
internal  carotid  within  the  cavernous  sinus,  thrombosis  of  the  ophthalmic 
veins,  aneurism  of  the  ophthalmic  artery,  intra-cranial  aneurisms,  etc., 
and,  in  other  instances,  it  forms  the  prominent  feature  of  a  typical  group 
of  symptoms,  i.  e.,  Exophthalmic  goitre. 

Exceptionally  it  may  exist  with  undisturbed  function  of  the  eye,  and 
without  resulting  in  discomfort  or  annoyance  to  the  individual.  The  only 
case  I  have  been  able  to  find  on  record,  illustrative  of  this  rare  type,  is 
referred  to  and  described,  under  the  term  simple  exophthalmos,  by  Macken- 
zie, in  his  work  on  the  eye. 

1  Habershon.    Lon.  Lancet,  1863,  p.  518. 

2  Wilks.    Guy's  Hospital  Reports,  1857. 

3  Loc.  cit.,  p.  63. 


1885.]        Sattlek,  One-sided  Transitory  Exophthalmos.  487 


Dislocation  of  the  eyeball  is  due,  in  the  largest  number  of  cases,  to  mechanical 
causes,  and  is  pathognomonic  of  the  various  inflammatory  affections  of  the  orbit, 
attended  by  exudative  and  inflammatory  hypertrophy  of  the  retro-bulbar  tissues, 
also  of  tumors,  cysts,  aneurisms,  etc.  ; — Endocapsulitis — also  of  all  traumatic 
lesions  attended  by  extravasation  of  blood,  with  or  without  fracture  of  the  bony 
walls.  It  is  met  with  after  various  operative  procedures — optico-ciliary  neurec- 
tomy, and  more  rarely  after  tenotomy  of  the  recti  muscles.  It  has,  with  few 
exceptions,  been  the  invariable  concomitant  of  a  large  group  of  cases,  described 
by  the  term  which  marks  its  chief  or  most  prominent  symptom,  i.  e.,  pulsating 
exophthalmos.  Mechanical  causes  in  adjacent  regions  also  frequently  decree  dis- 
location of  the  globe,  cysts  of  the  ethmoid,  disease  of  the  Antrum  Highmorii, 
etc. 

In  other  instances  mechanical  causes  within  or  in  the  immediate  neighborhood 
of  the  orbit,  cannot  be  assigned  to  account  for  the  prominence  of  the  eyes,  which 
may  vary  in  degree  of  protrusion  and  time  of  duration — it  may  even  be  periodic 
and  transitory — Exophthalmic  goitre. 

In  another  class  of  cases,  exophthalmos  occurs  in  connection  with  a  modifica- 
tion of  the  general  arterial  tension  in  Morbus  Brightii  and  cardiac  lesions,  and 
again  it  may  develop  suddenly,  and  no  assignable  cause,  either  intra-  or  extra- 
orbital  or  general,  can  be  upheld  to  account  for  it. 

With  the  exception  of  the  case  reported  by  Mackenzie,  mentioned  also 
by  Haynes  Walton,  no  reference  is  made  by  other  authors  to  a  form  of 
exophthalmos,  unilateral,  and  not  attended  by  disturbance  of  function  of 
the  eye  or  of  the  general  comfort  of  the  individual. 

Professor  Berlin,1  in  an  exhaustive  chapter  on  diseases  of  the  orbit, 
mentions  the  various  synonyms  for  displacement  of  the  globe,  but  no  men- 
tion is  made  of  this  physiological  variety  of  exophthalmos,  generally 
one-sided  with  undisturbed  function  and  muscular  movements  of  the  eye. 
So  slight  is  it  at  times  as  to  be  hardly  noticeable  ;  a  recession  even  of  the 
globe,  or  enophthalmos,  may  exist,  which,  after  a  brief  interval,  either  the 
result  of  change  of  position  of  the  body  or  head  or  by  compression  of  the 
tissues  of  the  neck,  gives  way  to  a  sudden  and  marked  protrusion. 

The  following  is  the  report  of  Mackenzie's  case : — 

Case  196. — The  patient  was  a  cooper  by  trade,  and  was  admitted  at  the  Glas- 
gow Eye  Infirmary  for  catarrho-rheumatic  ophthalmia,  affecting  chiefly  the  right 
eye.  After  he  had  attended  for  a  few  days,  is  was  discovered  that  if  he  stooped 
forwards,  although  only  for  a  few  minutes,  he  felt  as  if  something  was  filling  or 
pressing  above  his  right  eye,  which  immediately  began  to  protrude.  On  raising 
his  head,  the  protrusion  was  very  striking.  In  this  state  he  saw  indistinctly  with 
the  eye.  It  soon  began  to  retire,  and  in  a  few  minutes  was  in  its  natural  place. 
He  had  the  complete  power  of  moving  the  eye,  when  in  its  natural  situation,  and 
moved  it  considerably  even  while  it  was  displaced.  The  iris  moved  naturally. 
He  complained  of  considerable  pain  in  the  orbit,  which  was  relieved  by  venesec- 
tion and  the  use  of  mercurial  purges.  He  stated  that  the  protrusion  of  the  eye 
commenced  about  five  years  before  "his  application  at  the  Eye  Infirmary,  after 
carrying  a  heavy  load  upon  his  back.  It  was  difficult  to  assign  any  satisfactory 
explanation  of  the  case.  The  most  likely  conjecture  seemed  to  be  that  the  pro- 
trusion depended  on  a  varicose  state  of  the  ophthalmic  veins,  the  blood  flowing 
back  through  these  vessels  into  the  sinuses  of  the  dura  mater,  when  the  head  was 
elevated  or  thrown  back,  again  to  gravitate  into  them,  in  their  relaxed  state,  when 
the  head  was  bent  forward.  There  must  also  have  been  a  defective  tonicity 
of  the  muscles. 


Handbucli  der  Gesammten  Augenheilkunde.   Graefe,  Saemisch. 


488  Sattler,  One-sided  Transitory  Exophthalmos.  [April 

The  phenomenon  of  protrusion  in  this  case  was  noticed  accidentally, 
whilst  the  patient  was  under  treatment  for  another  affection  of  the  eyes. 
This  peculiarity  of  the  eye  had  been  known  to  the  patient  for  five  years, 
and  its  occurrence  was  associated  with  the  carrying  of  a  heavy  load.  It 
was  unattended  by  discomfort,  and  only  occurred  when  the  patient  was 
obliged  to  assume  certain  positions,  or  voluntarily  assumed  them,  to 
demonstrate  the  protrusion.  Change  of  posture  or  simple  elevation  of 
the  head  caused  a  prompt  disappearance  of  the  exophthalmos. 

It  will  be  seen  that  the  report  of  the  following  case,  the  subject  not 
seeking  advice  about  the  "  peculiarity,"  as  he  termed  it,  of  his  left  eye, 
but  simply  to  be  advised  in  reference  to  spectacles,  as  he  was  becoming 
presbyopic,  resembles  in  many  particulars  the  interesting  case  of 
Mackenzie,  and  yet  it  differs  in  many  respects  from  it,  in  that  additional 
features  of  interest  existed.  The  man  had  noticed  it  for  25  years.  He 
could  not  connect  its  occurrence  with  an  injury.  It  had  never  occasioned 
him  discomfort.    The  vision  of  the  eye  had  continued  undisturbed. 

When  quietly  seated  or  standing,  the  left  eye  was  not  prominent  as 
compared  with  the  fellowr-eye,  but,  on  the  contrary,  it  had  receded  into 
the  orbit  to  such  a  degree,  that  its  sunken  or  enophthalmic  state  was  as 
striking  and  conspicuous  as  a  few  moments  later  the  opposite  symptom  of 
exophthalmos,  which  wras  brought  about  by  stooping  forwards  or  throwing 
the  head  backwards. 

I  can  best  express  the  appearance  of  the  left  eye  by  stating  that  it  had 
"  an  artificial  eye"  expression,  and  my  first  impression  on  seeing  the  man 
at  a  distance  was,  that  the  peculiar  sunken  state  was  due  to  anophthalmos 
and  the  wearing  of  an  artificial  eye.  That  the  sunken  state  of  the  eye, 
when  the  patient  was  quietly  conversing,  had  probably  resulted  in  conse- 
quence of  the  absorption  of  the  retro-bulbar  adipose  tissue,  due  to  the  re- 
peated emptying  and  filling  up  of  the  tortuous  and  elastic  vascular  channels 
in  the  apex  of  the  orbit,  is  probable.  It  is  a  question  of  surmise,  although 
with  strong  probability  it  can  be  inferred,  that  a  varicose  or  dilated  state 
of  the  tributary  veins  of  the  cavernous  sinus,  the  superior  and  inferior 
ophthalmic  veins  existed,  and  perhaps,  also,  that  an  obstruction  or  tem- 
porary interference,  owing  to  the  existence  of  an  anatomical  peculiarity 
of  some  kind,  impeded  the  venous  current  in  the  principal  venous  outlet 
of  the  orbit,  the  cavernous  sinus,  whenever  the  patient  assumed  a  con- 
strained position. 

The  following  is  a  brief  report  of  the  case : — 

Case  J.  L.  B.,  aet.  46.  He  is  unable  to  assign  the  exact  date  when  his 

attention  was  first  attracted  to  the  peculiarity  of  his  left  eye.  To  the  best 
of  his  recollection,  it  was  in  his  18th  year  that  he  first  experienced  a  feel- 
ing of  fulness  and  protrusion  of  the  left  eye  ;  he  is  confident  it  existed 
at  the  age  of  21.  At  this  period  he  consulted  a  physician,  who  dis- 
covered the  sunken  condition  of  the  eye,  but  who  failed  to  discover  any 
disturbance  of  vision  or  other  defect ;  much  less  was  he  able  to  account 


1885.]        Sattler,  One-sided  Transitory  Exophthalmos.  489 


for  or  explain  the  sunken  state  and  the  exophthalmos.  He  was  a  sufferer 
from  so-called  dyspepsia  for  many  years,  but,  although  he  referred 
repeatedly  to  the  peculiarity  of  his  left  eye  to  his  physicians,  no  desire  or 
attempt  on  their  part  to  investigate  this  rare  symptom  was  elicited. 

Stat,  praes.  Man  of  average  height  and  weight.  No  marked  asymmetry 
of  face  or  cranium;  no  recognizable  difference  on  inspection  and  palpation, 
between  the  orbital  openings.  No  history  of  hereditary  tendency  to 
physical  peculiarities.  No  disturbance  of  sympathetic.  No  history  of 
marasmus  following  physical  exhaustion  or  protracted  disease.  No  car- 
diac disease. 

V — -1 .  r.  e.  ;  V=l.  1.  e. ;  Presbyop.  1.  D  ;  reads  1  Sn. 

Inspection  of  face  discloses  no  difference  between  the  two  eyes,  with 
the  exception  that  the  left  appears  more  sunken.  A  difference  exists  in 
the  vertical  diameter  of  the  palpebral  fissures  ;  the  left  is  smaller.  With 
closed  lids,  in  the  sitting  posture,  there  is  a  perceptible  difference  between 
the  prominence  of  the  two  eyes.  The  left  shows  a  deep  concavity  just 
below  the  superior  orbital  margin.  On  opening  and  closing  the  lids  the 
excursion  of  the  upper  lid  of  the  left  eye  is  perceptibly  retarded  on 
account  of  the  recession  of  the  globe. 

The  orbital  tension  of  the  left  side  is  markedly  diminished,  even  though 
the  eye  appears  sunken.    The  tension  of  the  right  orbit  is  normal. 

Walking  briskly  across  the  room^  or  resorting  to  muscular  exercise  with 
the  arms,  influences  and  affects  the  position  of  the  left  eye ;  it  becomes 
more  prominent.  Stooping  forward  only  a  few  seconds  causes  a  marked 
displacement  of  the  eye,  which,  with  a  little  pressure  and  even  without 
it,  recedes  quickly  when  the  erect  posture  is  again  assumed. 

Inclination  of  the  head  backwards,  the  patient  in  a  standing  position, 
affords  a  conclusive  and  striking  demonstration  of  both  the  rapidity  of 
occurrence  and  also  the  degree  of  exophthalmos. 

The  advance  forwards  or  exit  of  the  eye  out  of  the  cavity  of  the  orbit 
can  be  readily  observed,  and  the  time  and  extent  of  the  excursion  measured. 
In  fifteen  seconds  it  reaches  its  height,  and  the  eye  advances  forwards 
twenty-eight  mm.  At  first,  or  until  it  has  advanced  about  ten  mm.,  it  is 
protruded  directly  forwards,  then  it  diverges  and  projects  in  the  axis  of 
the  orbit.  The  lids,  corresponding  to  the  period  of  greatest  prominence, 
appear  congested,  tense,  and  stretched  to  their  utmost  capacity. 

With  closed  eyelids,  the  exophthalmos,  or  advance  forwards,  is  not  so 
marked,  and  measures  about  eighteen  mm.  if  the  lids  be  separated  and 
held  by  the  thumb  and  index  finger,  whilst  the  head  is  inclined  back- 
wards. The  eye  advances,  and  can  readily  be  strangulated  or  dislocated 
completely. 

Firm  compression  of  the  left  side  of  the  neck  produces  the  same  degree 
of  prominence.    Holding  the  breath,  straining,  etc.,  also  brings  it  about. 

In  the  recumbent  posture  the  left  eye  appears  a  little  more  prominent, 
and  the  sunken  or  enophthalmic  appearance  is  not  so  marked. 

The  muscular  movements  of  the  eye  are  not  interfered  with,  and  bin- 
ocular vision  exists  until  the  exophthalmos  exceeds  certain  limits.  Vision 
remains  undisturbed  until  the  prominence  becomes  great  and  the  eye 
diverges.  During  moderate  degrees  of  exophthalmos  the  muscular  excur- 
sion and  pupillary  movements  remain  undisturbed. 

Ophthalmoscopic  examination  does  not  disclose  anything  noteworthy  or 
abnormal. 


490      Claiborne,  Hiatus  in  Anterior  Pillar  of  the  Fauces.  [April 


Article  XYI. 

Hiatus  in  the  Anterior  Pillar  of  the  Fauces  of  the  Right  Side, 
with  Congenital  Absence  of  Tonsil  on  either  side.  By  J.  Her- 
bert Claiborne,  Jr.,  M.D.,  Clinical  Assistant  to  the  Chair  of  Ophthalmo- 
logy in  the  New  York  Polyclinic. 

There  fell  under  my  observation  in  the  office  of  Dr.  E.  Gruening,  of 
New  York,  a  case  of  hiatus  in  the  anterior  pillar  of  the  fauces  of  the 
right  side,  with  congenital  absence  of  tonsil  on  either  side. 

Case  I.  occurred  in  the  case  of  a  man,  58  years  old,  who,  on  looking 
at  his  throat  in  the  mirror,  accidentally  discovered  an  unnatural  opening 
on  the  right  side.  The  hiatus  was  not  complete,  but  consisted  of  a  niche 
or  furrow  of  a  uniform  breadth  of  three  lines.  The  furrow  commenced 
above  and  slightly  inward,  on  a  level  with  the  base  of  the  uvula,  and  ex- 
tended downward  and  outward,  about  the  middle  of  the  anterior  pillar  of  the 
fauces,  for  the  distance  of  about  six  lines,  to  a  level  with  the  upper  border 
of  the  alveolar  process.  The  furrow  was  most  shallow  above,  and  gradu- 
ally became  deeper,  till  it  attained  at  its  inferior  extremity  the  depth  of 
about  a  line  to  a  line  and  a  half.  Just  below  the  centre  of  the  furrow 
and  nearer  to  its  median  than  its  temporal  edge,  was  a  fistulous  opening, 
oblong  in  shape,  with  its  long  axis  downward,  and  about  one  line  to  a 
line  and  a  half  wide  ;  on  passing  the  end  of  a  probe  into  this  opening,  it 
seemed  at  first  blind,  but,  by  giving  the  probe  a  downward,  inward,  and 
slightly  backward  inclination,  it  was  made  to  pass  into  the  space  between 
the  anterior  and  posterior  pillars  of  the  fauces,  where  it  could  be  distinctly 
seen.  Neither  in  this  space  nor  in  the  corresponding  space  on  the  left 
side  was  there  any  trace  of  tonsil.  The  edges  of  the  furrow  were  no- 
where sharply  defined,  and  were  soft  and  smooth.  There  were  no  signs 
of  cicatricial  tissue.  The  patient  had  no  recollection  of  any  throat  trouble 
which  might  have  caused  it  ;  and,  in  fact,  was  not  aware  of  it  till  he  had 
discovered  it  accidentally,  as  before  mentioned.  This  abnormal  condition 
has  been  observed  a  few  times,  but  in  every  case  the  hiatus  has  been 
greater  and  on  both  sides. 

Dr.  J.  Solis  Cohen  (Diseases  of  the  Throat  and  Nasal  Passages,  2d 
edition,  p.  206)  speaks  of  the  anomaly,  and  accompanies  it  with  a  cut 
(Fig.  59). 

He  says  :  An  occasional  anomalous  condition  of  the  palate  consists  in  a 
separate  mucous  investment  of  the  palato-glossus  muscle  in  the  anterior 
fold  of  the  palate ;  leaving  on  either  side  an  opening  which  might  be  mis- 
taken for  ulcerative  destruction  of  tissue. 

Cohen  also  refers  to  the  case  reported  by  Dr.  Wolters,  of  Gottingen, 

which  is  given  below,  together  with  one  very  similar,  reported  by  Dr.  O. 

Chiari,  of  Vienna. 

Case  II.,  reported  by  Dr.  Wolters,  of  Gottingen  (Zeitschrift  fur  Rationelle 
Medecin,  1859). — Whilst  the  tonsils,  under  ordinary  conditions,  are  completely 
inclosed  in  the  niche  or  isthmus  which  is  formed  by  the  palato-glossal  and  the 
palato-pharyngeal  muscles  (with  the  exception  of  a  small  portion  of  their  inner 
circumference,  which  projects  toward  the  median  line  a  little  beyond  the  inner 


1885.]  Dickey,  Congenital  Ectopia  Lentis.  491 

border  of  the  palato- glossal  muscle),  their  anterior  plane  presented  to  my  greatest 
astonishment  a  cord  stretched  obliquely  from  above  and  within,  arising  from  the 
uvula  and  extending  downward  and  slightly  outward  to  the  side  of  the  root  of  the 
tongue.  At  the  first  sight,  1  thought  it  was  quite  probable  that  an  escharotic  had 
been  applied  on  account  of  some  ulcerative  process,  or  some  other  mechanical  in- 
jury had  caused  the  defect  in  the  anterior  pillars  (the  posterior  were  in  their  nor- 
mal integrity)  ;  apart,  however,  from  the  symmetrical  arrangement  on  either  side, 
a  closer  observation  convinced  me  of  the  groundlessness  of  my  original  opinion  ; 
for,  not  only  were  there  not  the  slightest  traces  of  cicatrization  to  be  found,  but 
also  the  patient  had  no  recollection  of  any  pain  in  the  part  in  question  ;  indeed, 
up  to  the  present  moment,  he  had  never  had  a  suspicion  of  the  unusual  condi- 
tion. Both  of  the  appearances  mentioned  above,  stretching  from  the  uvula  to 
the  side  of  the  root  of  the  tongue,  were  nothing  else  than  the  isolated  palato- 
glossal muscle. 

Case  III.,  reported  by  Dr.  O.  Chiari,  of  Vienna  (MonatsscTlrift  fur  Ohren- 
tieilkunde). — Both  anterior  pillars  were  characterized  by  an  opening,  which  was 
greater  on  the  left  side  than  on  the  right.  They  were  both  equally  oval ;  the 
left  was  something  above  10  ctm.  long,  and  3  mm.  wide.  The  borders  of  these 
openings  were  smooth,  and  gave  no  trace  of  cicatrization.  The  mucous  mem- 
brane of  the  posterior  wall  of  pharynx  was  studded  in  its  upper  part  with  large 
crranulations,  but,  beneath,  especially  on  the  lateral  parts,  it  was  pale  and  thin. 
The  mucous  membrane  of  nose  and  larynx  was  pale.  The  posterior  pillar  and 
the  uvula  were  normal.  The  questioning  of  the  parent  gave  the  history  of  a 
throat  trouble  six  years  before — in  the  course  of  which  there  might  have  been 
ulceration.  The  exactly  symmetrical  condition,  and  the  smoothness  of  the  edges 
of  the  openings  are  against  their  ulcerative  origin  :  so  much  the  more  so,  since 
there  was  no  sign  of  cicatrization. 

I  refer,  by  permission  of  Dr.  A.  Schapringer,  of  New  York,  through 
whose  cordial  courtesy  I  have  been  put  in  possession  of  the  literature 
bearing  upon  the  subject,  to  a  case  under  his  own  observation,  very  similar 
to  that  reported  by  Dr.  Wolters,  which  he  kindly  demonstrated  to  me, 
and  which  is  to  appear  shortly  in  the  Monatsschrift  fur  Ohrenheilhunde. 

Though  the  case  reported  by  myself  tallies  in  many  particulars  with 
those  subjoined,  the  presence  of  the  defect  on  one  side  only,  and  the  con- 
genital absence  of  tonsil  on  either  side,  render  it  of  no  ordinary  scientific 
interest. 


Article  XVII. 

A  Case  of  Congenital  Ectopia  Lentis.    By  John  L.  Dickey, 
A.M.,  M.D.,  of  Wheeling,  West  Virginia. 

A  congenital  dislocation  of  the  crystalline  lens  is  certainly  sufficiently 
rare  to  justify  a  report  of  the  following  case. 

Nina  McCombs,  a  slender,  light-complexioned  girl  thirteen  years  old, 
was  brought  to  me,  by  her  father,  on  account  of  defective  vision.  She  had 
never  been  well,  her  parents  thought,  from  the  time  she  was  old  enough 
to  observe,  and  when  a  child  would  grope  for  her  playthings,  or  any  ob- 
ject she  would  attempt  to  take.  She  could  distinguish  the  forms,  but  not 
the  features,  of  persons  near  by,  and  she  could  not  distinctly  see  objects 


492 


Dickey,  Congenital  Ectopia  Lentis. 


[April 


at  a  great  distance,  as  a  house  on  a  hill,  a  mile  or  more  away.  She 
learned  to  read  by  holding  the  book  in  actual  contact  with  her  nose  and 
forehead,  and  being  bright  and  studious,  always  stood  at  the  head  of  her 
classes.  The  patient  is  the  second  of  six  children,  five  of  whom  are 
living.  She  was  a  full  term  child,  but  was  small  at  birth,  weighing 
only  four  pounds.  She  never  had  a  fall,  or  severe  blow  on  the  head,  or 
convulsions,  and  only  slight  attacks  of  the  ordinary  diseases  of  childhood. 
The  rest  of  the  family  and  immediate  relations  all  have  good  eyes  and 
normal  vision. 

On  examination,  the  eyes  seemed  somewhat  flattened  with  deep  anterior 
chambers.  The  irides  were  of  a  peculiar  ash  color,  with  well-marked 
striae  of  a  darker  hue,  and  were  extremely  sensitive  to  light,  contracting 
quickly  to  form  pin-hole  pupils.  The  irides  were  both  tremulous,  except 
in  the  upper  part,  and  a  slight  nystagmus  kept  them  constantly  shaking, 
giving  a  beautiful  effect,  like  the  wavy  motion  of  thin  satin  curtains. 

In  order  to  make  a  satisfactory  ophthalmoscopic  examination  a  mydri- 
atic was  used  (duboisia  grs.  ij-sj).  With  a  -j-  6D  glass,  by  the  direct 
method,  could  be  readily  seen  the  dark,  curved  outline  of  the  crescent  of 
the  lens,  clearly  defined  against  the  red  background.  About  one-sixth  of 
the  lens  was  visible  in  either  eye,  occupying  about  one-fourth  part  of  the 
dilated  pupil.  In  the  right  eye  the  segment  of  the  lens  was  in  the  upper 
and  nasal  quadrant  of  the  pupillary  space ;  in  the  left  eye  it  was  directly 
above,  in  the  middle.  Both  lenses  were  transparent,  the  retinal  vessels 
being  distinctly  visible  through  them.  They  seemed  perfectly  immovable, 
not  responding  at  all  to  the  different  motions  of  the  eye,  and  were  tilted 
at  such  an  angle  as  would  make  them  occupy  the  same  relative  position  to 
the  wall  of  the  globe  as  the  normal  lens.  The  vitreous  was  perfectly  clear. 
The  fundi  seemed  normal.  There  was  a  marked  physiological  conus  on 
the  temporal  side  of  the  left  disk.  Both  eyes  proved  afterward  to  be 
slightly  amblyopic,  the  left  more  so  than  the  right. 

The  results  of  a  careful  refraction  proved  to  be  as  follows : — 
3  15 

V.  0.  D.=— ,  +  13d  sPh-  e  +  3d       ax.  90°  ==  — 

CC  w  L 

n  15 

V.  O.  S.  =  —  ,  +  13D  sPh-^  4-  3d  ^-ax.  90°=  

CC    1  w  n  LXX 

Of  course,  it  proved  to  be  the  same  with  duboisia  as  without  it.  With- 
out glasses  the  patient  could  read  bourgeois  type  at  one  and  a  half,  and 
pica  at  two  inches.  With  the  glasses  she  could  read  pearl  at  the  normal 
distance  of  twelve  inches.  The  angle  and  amount  of  astigmatism  suggest 
that  the  vertical  curve  of  the  cornea,  in  both  eyes,  had  been  preserved 
by  the  support  afforded  by  the  fixed  position  of  the  lenses  above. 

The  satisfaction  afforded  by  the  glasses  was,  of  course,  very  great,  for 

3  .  15 

by  improving  the  vision  from  — ; t0  —  they  practically  restored  the  blind 

C  C  L 

to  sight. 


1885.] 


493 


REVIEWS. 


Art.  XVIII  The  Principles  and  Practice  of  Gynaecology.    By  Thos. 

Addis  Emmet,  M.D.,  LL.D.,  Surgeon  to  the  Woman's  Hospital  of 
the  State  of  New  York  ;  ex-President  of  the  American  Gynaecological 
Society,  and  New  York  Obstetrical  Society,  etc.  etc.  etc.  Third 
edition,  thoroughly  revised  ;  with  one  hundred  and  fifty  illustrations. 
Philadelphia:  Henry  C.  Lea's  Sons  &  Co.,  1884. 

By  the  time  a  book  has  reached  a  third  edition  its  character  is  pretty 
well  known  ;  it  has  taken  a  place  among  standard  works  on  the  subject, 
and  there  is  nothing  for  the  journalist  to  do  but  to  chronicle  the  event  and 
congratulate  the  author.  In  this  instance,  however,  there  is  an  exception, 
not  as  to  the  congratulations  which  are  heartily  tendered,  but  as  to  the 
notice  required  of  the  work.  Very  many  changes  have  been  made  in  this 
edition.  The  book  appears  in  smaller  type,  set  more  compactly,  so  that 
while  it  now  has  about  the  same  number  of  pages  as  formerly,  it  contains 
a  great  deal  more  reading  matter.  Some  of  the  additions  are  the  record 
of  progress  which  even  four  years  have  furnished  to  this  rapidly  advancing 
branch  of  medicine  ;  others  consist  of  reports  of  new  cases  illustrating 
doctrines,  and  of  quotations  from  other  writers  sustaining  the  author's 
teachings.  But  far  more  important  changes  than  these  are  indicated  in 
the  preface.  It  is  there  stated  that  much  of  the  first  edition  was  expunged, 
or  very  much  modified,  by  the  advice  of  a  friend,  the  views  being  deemed 
so  widely  different  from  those  generally  accepted  as  likely  to  interfere  with 
the  success  of  the  book.  What  those  views  were,  as  originally  written, 
we  do  not  know,  but  the  doctrines  of  the  work,  as  presented,  were  cer- 
tainly novel,  if  not  revolutionary.  The  chief  points  were,  briefly,  the 
importance  assigned  to  venous  congestion,  the  elevation  of  pelvic  cellu- 
litis to  the  highest  position  among  pathological  processes,  the  recognition 
of  cicatricial  tissue  as  the  source  of  reflex  symptoms,  a  denial  of  inflam- 
mation of  the  uterus,  except  puerperal,  and  consequent  rejection  of  intra- 
uterine medication.  All  these  were  urged  with  great  positiveness, 
and  with  considerable  harsh  criticism  of  the  profession.  We  have 
now  a  new  edition  in  which  a  wider  application  is  made  of  the 
author's  peculiar  views,  in  which  they  are  more  forcibly  urged,  and  in 
which  new  doctrines,  the  result  of  further  experience,  are  presented. 
While,  therefore,  the  very  extended  notice  given  to  the  first  edition  pre- 
cludes the  necessity  of  a  full  examination  of  this,  we  have  yet  to  give  for 
the  benefit  of  our  readers  some  idea  of  what  is  in  many  respects  a  new 
book,  and  try  to  present  examples  of  the  modification  which  the  author's 
views  have  undergone,  and  the  nature  of  the  new  doctrines  promulgated. 

Naturally  we  turn  first  to  some  of  those  subjects  with  which  Dr.  Emmet's 
name  is  most  closely  connected,  and  select  the  one  by  which  he  became 
most  widely  known — laceration  of  the  cervix  and  the  operation  for  its 
No.  CLXXVIII  April,  1885.  32 


494 


Reviews. 


[April 


repair.  To  this  subject  twenty  more  pages  are  devoted  in  this  than  in  the 
last  edition.  Among  the  new  matter  we  are  first  struck  with  the  doctrine 
that  it  is  not  the  laceration  per  se  which  is  the  origin  of  the  consequent 
troubles,  but  the  blood-poisoning  and  pelvic  cellulitis  consecutive  to  it. 
Many  of  these  lacerations,  we  are  told,  heal  up  without  difficulty ;  more 
would  do  so  if  the  febrile  disturbance  following  labor  was  referred  to  its 
real  cause  and  treated  accordingly,  a  practical  hint  the  value  of  which  no 
obstetrician  will  overlook.  But  the  author  does  not  point  out  how  a  septic 
process  arising  from  a  tear  of  the  perineum  is  to  be  distinguished  from 
one  caused  by  a  cervical  lesion.  The  doctrines  that  blood-poisoning  and 
consequent  cellulitis  are  the  chief  factors  are  too  important  not  to  be 
presented  in  the  author's  words  : — 

"A  laceration  of  the  cervix,  however  extensive,  will  rapidly  heal  without  an 
untoward  symptom,  unless  blood-poisoning  should  take  place.  This  occurrence 
is  always  accompanied  by  some  general  disturbance,  and  is  marked  by  a  septic 
cellulitis,  which  obstructs  the  pelvic  circulation  so  as  to  arrest  involution  and 
repair  of  the  injury." 

"  When  this  injury  has  been  received  there  has  existed  from  the  beginning 
a  pelvic  cellulitis,  of  supposed  septic  origin,  and  as  long  as  this  inflammation 
remained  afterwards,  the  leucorrhoeal  discharges  continued  and  the  raw  surfaces 
remained  unhealed.  In  consequence  of  the  obstructed  circulation,  due  to  the 
cellulitis,  the  parts  began  to  roll  out  soon  after  the  reception  of  the  injury,  and 
as  the  woman,  with  arrested  involution,  assumed  the  upright  position  certain 
mechanical  forces  exaggerated  the  difficulty." 

The  contrast  can  be  better  seen  by  the  following  extracts  placed  in 
juxtaposition  : — 


"Whenever  the  rent  has  extended 
to  the  vaginal  junction,  or  beyond, 
there  will  exist  a  tendency  for  the 
tissues  to  roll  out  from  the  uterine  canal 
as  soon  as  the  wound  assumes  the 
upright  position." — Second  ed. 


"  Whenever  the  rent  has  extended  to 
the  vaginal  juncion,  or  beyond,  and  a 
cellulitis  has  been  set  up,  there  will  exist 
a  tendency  for  the  tissue  to  roll  out  from 
within  the  uterine  canal,  to  be  greatly 
increased  as  the  woman  assumes  the  up- 
right position." — Third  ed. 


Again,  on  page  456,  it  is  set  forth,  that  "  so  long  as  the  cellulitis  remains 
to  any  extent,"  not  only  will  the  woman  suffer  from  pelvic  symptoms, 
difficulty  of  locomotion,  and  menstrual  disturbances,  but  there  will  follow 
headache,  disordered  mental  action,  insomnia,  with  melancholia  and  other 
forms  of  insanity.  All  these  consequences  are  referred  to  the  cellulitis, 
and  not  a  word  is  said  in  connection  with  the  laceration. 

Not  only  these  more  or  less  remote  symptoms,  but  the  cervical  catarrh 
is  now  referred  rather  to  a  cellulitis  than  to  the  injury  of  the  cervix 
itself : — 

"  So  far  as  the  relation  of  cause  and  effect  exists,  I  am  positive  in  the  opinion 
that  a  follicular  discharge  is  never  found  existing  to  any  extent  with  a  laceration 
of  the  cervix,  unless  some  pelvic  inflammation  is  also  present  which  can  be  detected 
at  least  by  means  of  a  rectal  examination.  The  increased  secretion  is  first  caused 
by  the  cellulitis,  and  as  the  mucous  and  submucous  tissues  become  more  congested 
they  roll  out  more  and  more  from  the  seat  of  laceration." 

In  the  last  edition  this  "  rolling  out"  of  the  tissues,  or  uterine  ectro- 
pion, was  the  direct  result  of  the  laceration,  produced  by  gravitation  of 
a  subinvoluted  uterus,  and  by  the  mechanical  influence  of  a  hypotheti- 
cal hitching  of  the  cervix  on  the  vaginal  walls  ;  now  it  is  the  result  of 


1885.]      Emmet,  Principles  and  Practice  of  Gynaecology. 


495 


cellulitis.  But  not  only  this:  formerly  the  "rolling  out"  was  the  one 
distinctive  evidence  of  the  lesion,  and  to  roll  in  with  tenacula  the 
everted  lips  of  the  cervix  was  the  demonstrative  proof  that  a  laceration 
existed.  Now,  it  is  no  proof  at  all !  marked  eversion  may  exist  in  a 
nulliparous  subject,  as  the  result  of  a  cellulitis,  and  may  be  cured  byjtreat- 
ment  of  this  cellulitis,  the  everted  surfaces  rolling  in  again  as  the  inflam- 
mation disappears,  and  a  virgin  os  remain  !  Such  a  case  is  reported  on 
page  460,  and  the  consequent  doctrine  results,  and  is  emphasized  by  italics, 
that  "preparatory  treatment  may  be  necessary  sometimes  even  to  make  a 
diagnosis  as  to  the  existence  of  the  lesion." 

Consequent  upon  these  doctrines  comes,  naturally  enough,  an  elevation 
of  the  importance  of  treatment,  with  the  admission  that  many  cases  can  be 
cured  without  operation.  Those  who  declined  to  receive  the  views  of  the 
former  editions,  and  who  maintained  that  there  was  some  mistake  about 
the  general  necessity  for  operative  interference,  will  read  this  portion  of 
the  book  with  great  satisfaction.  Dr.  Emmet  now  operates  on  a  much 
smaller  number  of  cases  than  formerly.  Moreover,  in  commenting  (p. 
485)  upon  the  results  obtained  by  one  of  his  enthusiastic  followers,  who 
has  operated  on  over  one  hundred  cases  without  any  preparatory  treatment 
whatever,  he  expresses  doubts  whether,  if  the  after  history  of  these  cases 
were  known,  the  results  would  be  satisfactory,  and  he  makes  the  following 
admission,  most  damaging  to  the  position  heretofore  given  to  the  opera- 
tion : — 

"  A  temporary  benefit  is  gained  in  almost  every  instance  after  the  operation  ; 
but  it  is  the  exception  to  the  rule  if  a  relapse  does  not  take  place  within  a  few 
months  after,  if  the  preparatory  treatment  has  not  been  administered  beforehand, 
and  the  operation  employed  at  the  last  with  the  chief  object  of  keeping  what  had 
been  thus  gained." 

In  the  chapter  on  the  operation  for  repair  of  laceration  of  the  cervix 
there  is  not  only  the  candid  admission,  but  all  through  the  text  there  is 
the  evident  recognition  of  the  fact  that  this  operation  has  been  abused. 
It  could  not  be  otherwise  as  human  nature  is  constituted.  It  having  been 
demonstrated  that  an  injury  resulting  from  childbirth  was  sometimes  the 
sole  cause  of  grievous  symptoms  formerly  attributed  to  other  pathological 
conditions,  it  was  natural  to  elevate  the  truth  to  the  dignity  of  a  general 
law,  while  the  temptation  to  a  brilliant  cure  is  always  strong.  Thus  the 
cervix  and  the  perineum  have  been  made  to  bear  the  brunt  of  a  vast  amount 
of  surgery.  It  is  easy  to  find  lesions  by  those  who  are  anxious  to  find  what 
they  seek.  For  the  abuse  of  this  operation  Dr.  Emmet  is  not  to  blame. 
His  discovery  of  the  importance  of  the  lesion,  and  his  operation  for  its 
repair  have  been  accepted  generally  by  the  profession  of  the  world  as  valu- 
able contributions.  Nevertheless,  this  protest  of  the  discoverer  and  origi- 
nator against  abuse  of  the  measure  was  needed,  and  it  will  do  much  to 
restrain  it  within  just  limits. 

In  a  former  review  of  this  work  we  expressed  doubt  as  to  the  import- 
ance of  cicatricial  tissue  in  a  healed  cervical  laceration  as  the  source  of 
reflex  symptoms.  It  is  but  just  to  say  that  further  experience  sustains  Dr. 
Emmet  in  this  point,  as  shown  by  numerous  instances  given  in  the  con- 
cluding chapter  on  this  subject,  nevertheless  accompanied  by  the  admis- 
sion (p.  486)  that  disappointment  is  often  experienced  in  operating  for 
such  symptoms,  and  that  it  is  impossible,  with  our  present  knowledge,  to 
select  the  cases  with  precision. 


496 


Reviews  . 


[April 


That  portion  of  the  book  devoted  to  injuries  of  the  pelvic  outlet  fur- 
nishes the  most  striking  example  of  the  new  doctrines  which  the  author 
promulgates  in  this  edition.  They  are  such  as  to  arrest  the  attention  of 
every  reader,  and  so  widely  different  from  generally  accepted  views  as  to 
demand  notice.  The  chapter  upon  laceration  of  the  perineum  involving 
the  sphincter  ani  stands  substantially  as  before,  and  to  this  form  of  injur}' 
the  term  "  laceration  of  the  perineum"  is  now  restricted.  Chapter  XX. 
is  now  headed  "  So-called  Lacerations  of  the  Perineum,"  and  an  entire 
new  chapter  precedes  these  upon  "  Prolapse  of  the  Posterior  Wall  of  the 
Vagina."  It  is  here  that  we  find  doctrines  which  are  revolutionary,  for 
the  value  of  the  "perineal  body"  and  of  the  perineum  itself  as  structures 
affording  support  to  the  uterus  is  plainly  and  emphatically  denied  !  That 
triangular  body,  which  has  been  considered  so  essential  a  part  of  the 
perineum,  and  which  it  is  so  important  to  restore  in  every  operation  upon 
these  parts  is  no  longer  worthy  of  any  consideration  !  The  opening  clause 
of  the  first  extract  is  certainly  extraordinary  : — 

"  Scarcely  any  author  has  attempted,  at  any  length,  to  show  the  use  or  sup- 
posed physiological  bearing  of  the  perineal  body,  but  all  have  reiterated  the 
accepted  statement  that  it  is  the  main  support  upon  which  rest  the  pelvic  organs 
through  the  aid  of  the  vaginal  canal.  On  this  supposition  no  little  ingenuity  has 
been  spent  in  the  repair  of  a  lacerated  perineum  by  the  building  up  of  a  body  far 
more  in  extent  than  nature  ever  furnished,  which  has  proved  often  an  obstruction 
to  the  entrance  of  the  vagina,  and  led  to  the  certainty  of  rupture  at  the  subse- 
quent labor." 

"  .  .  .  .  It  ean  be  shown  that  the  perineum  gives  no  support  to  the  uterus 
directly  or  indirectly.  Prolapse  of  the  uterus  never  occurs  directly  from  loss  of 
support  where  the  perineum  had  been  lacerated,  and,  unless  the  muscles  have 
been  involved  to  the  extent  of  rupture  through  the  sphincter  ani,  the  injury  sus- 
tained is  seldom  more  than  a  superficial  tear  through  the  skin,  and,  to  a  limited 
extent,  into  the  connective  tissue." 

The  chief  office  of  the  perineal  body,  if  not  its  only  office,  is  stated  to  be 
to  give  support  to  the  curve  of  the  rectum,  and  rupture  of  the  perineum  is 
said  to  produce  no  inconvenience,  after  the  parts  have  once  healed,  with 
rare  exceptions  in  which  reflex  symptoms  are  produced  by  cicatricial 
tissue.  The  author's  argument  cannot,  of  course,  be  given  in  full ;  its 
chief  point  is  the  extensive  laceration  sometimes  seen  without  consequent 
symptoms  and  the  great  distress  sometimes  observed  where  the  injury  is 
but  slight.  The  true  lesion,  according  to  the  author,  is  not  external,  but 
internal — subcutaneous  and  submucous — and  consists  of  laceration  of  por- 
tions of  the  muscles,  or  a  separation  of  the  fascia,  extending  from  the  sulcus 
on  each  side,,  from  its  connection  with  the  vaginal  outlet,  and  this  may 
occur  without  external  injury.  Anatomical  illustrations  or  diagrams 
should,  on  no  account,  have  been  omitted  here,  but  there  are  none.  Twelve 
years  have  elapsed,  the  author  says,  since  he  recognized  that  the  lost  sup- 
port was  to  be  restored  by  means  of  the  posterior  wall  of  the  vagina,  and 
for  three  years  past  he  has  been  performing  the  operation  for  this  purpose 
which  is  here  presented  and  described.  The  object  is  to  "  unite  the  pos- 
terior surface  of  the  perineum  to  the  recto-vaginal  wall."  The  description 
of  the  operation  is  not  satisfactory.  If  simplicity  be  the  measure  of  the  per- 
fection of  an  operation,  this  one  is  far  from  perfect.  Evidently  there  has 
been  an  omission,  as  three  tenacula  are  to  be  brought  together,  while  only 
two  have  been  mentioned.  By  the  aid  of  the  cut  readers  may  be  able  to 
understand  it;  to  us  this  cut  clearly  demonstrates  that  Dr.  Emmet  can 
pass  a  needle  through  tissues  in  a  more  curved  course  than  anybody  else 


1885.]     Emmet,  Principles  and  Practice  of  Gynaecology. 


497 


can.  Those  who  would  attempt  the  operation  should  note  the  particular 
directions  for  performing  it,  the  liability  to  failure  from  taking  up  just 
a  little  too  much  tissue,  or  from  not  judging  correctly  as  to  the  number  of 
sutures. 

The  advantages  of  the  new  operation  are  said  to  be  marked  : — 

"  No  comparison  can  be  drawn  in  regard  to  the  gain  to  the  patient  by  lessening 
the  suffering  and  discomfort  which  always  attended  every  method  as  formerly  used 
for  closing  a  lacerated  perineum." 

Turning  now  to  the  chapter  on  "  so-called  laceration  of  the  perineum," 
in  which  the  old  operation  is  described,  we  find  in  the  closing  paragraph 
the  two  operations  compared  and  read  : — 

"  Essentially  the  same  extent  of  vaginal  surface  is  denuded  by  both  operations, 
also  the  same  trefoil  shape  is  formed,    ....    exactly  the  same  surfaces  are 
united  by  both  operations.    .    .    .    The  object  is  essentially  the  same. 
The  only  difference  lies  in  the  direction  and  mode  of  introducing  the  sutures." 

The  author  calls  this  new  procedure  an  "  operation  for  diminishing  the 
vaginal  outlet."  Is  it  to  be  known  in  the  medical  world  as  another  "  Em- 
met's operation  ?"  With  the  conservative  teachings  of  this  edition  as  to 
the  operation  for  laceration  of  the  cervix,  and  with  the  open  admission  that 
that  has  been  abused,  is  there  now  another  operation  brought  forward  to 
run  the  same  course?  It  is  with  more  than  regret  that  we  read  the  indi- 
cations given  for  this  new  method,  part  of  which  we  italicize  : — 

"There  can  be  no  doubt  as  to  the  necessity  for  an  operation  after  tJie  vagi- 
nal canal  has  become  relaxed  from  any  cause,  or  when  the  perineum  has  been 
extensively  lacerated." 

Under  this  teaching  there  is,  of  course,  no  limit  to  the  number  of  patients 
that  can  be  submitted  to  the  operation.  If  followed,  gynaecology  will 
again  be  subjected  to  reproach.  What  effect  will  this  have  upon  the 
author's  reputation  ? 

Many  other  subjects,  some  of  them  of  deep  interest  and  of  great  prac- 
tical importance,  invite  attention.  Duty,  however,  impels  us  rather  to  call 
attention  to  some  changes  and  additions  which  we  think  should  have  been 
made  in  this  edition,  but  which  do  not  appear.  We  allude  particularly  to 
the  brief  attention  given  to  some  very  practical  points  and  every-day  dis- 
eases, as  compared  with  that  devoted  to  certain  operative  procedures. 
This  feature  of  Dr.  Emmet's  work  did  not  escape  observation  upon  the 
appearance  of  the  first  edition;  it  ought  not  to  pass  unnoticed  in  the  third. 
The  chapter  upon  sub-involution  of  the  uterus  may  be  specified.  It 
occupies  just  one  page  and  a  quarter.  Granted  that,  in  the  majority  of 
cases,  this  condition  of  the  uterus  is  secondary  to  some  lesion,  and  that 
under  the  head  of  the  primary  affection  its  treatment  has  been  considered, 
still  sub-involution  not  infrequently  comes  under  observation,  or  appears  to 
the  young  practitioner,  as  an  independent  disease.  Then  there  is  the  similar 
condition  of  "  malarial  congestive  hypertrophy,"  recognized  by  the  author 
in  one  of  the  first  chapters  of  the  book,  and  the  powerful  influence  of  iodine 
in  reducing  the  bulk  of  the  uterus  is  there  stated.  These  considerations 
force  the  conviction  that  more  space  should  have  been  demoted  to  this  con- 
dition and  its  treatment  have  been  more  fully  detailed,  even  at  the  risk  of 
some  repetition. 

The  same  observation  may  be  made  as  to  the  very  important  and  prac- 
tical subject  of  menstrual  derangements.    All  these  are  treated  of  in  one 


498 


Reviews. 


[April 


chapter  of  twenty-four  pages,  which  chapter  includes  also  all  the  author 
has  to  say  on  hysteria.  From  among  these  affections  we  may  select 
menorrhagia  as  one  which  shows  markedly  a  want  of  due  attention.  There 
is  a  class  of  these  cases,  coming  very  frequently  under  the  observation  of 
the  family  physician,  for  which  we  think  we  had  a  right  to  expect  infor- 
mation and  assistance  from  the  author.  They  are  cases  of  menorrhagia 
in  young  girls  just  as  the  periodical  function  begins.  The  affection  in  this 
class  of  subjects  dependent  upon  "a  condition  of  general  plethora,"  is 
recognized.  But  such  an  origin  does  not  obtain  in  a  respectable  minority 
of  cases.  Menorrhagia  is  frequently  found  in  young  girls  of  spare  habit, 
of  rapid  growth,  of  overtaxed  powers  at  school,  and  in  girls  of  a  marked 
"  ovarian  type,"  who  are  the  reverse  of  plethoric.  They  are  subjects  in 
which  every  right-minded  man  postpones  as  long  as  possible  any  inves- 
tigation as  to  an  organic  origin  of  the  trouble.  Meantime  their  treatment 
requires  both  judgment  and  skill,  and  the  young  practitioner  often  feels 
the  need  of  a  wise  counsellor. 

Again,  one  of  the  most  frequent  causes  of  menorrhagia  and  metrorrhagia 
as  they  come  under  the  observation  of  the  practitioner  is  retained  portions 
of  an  ovum.  This  cause  is  recognized  by  the  author,  but  it  is  coupled 
with  the  statement  that,  as  thus  arising,  the  derangement  does  not  come 
Avithin  his  purview  !  Why  it  does  not,  is  not  stated.  Consequently,  then, 
we  have  no  directions  for  treatment  of  such  cases  by  removing  the  cause 
with  the  curette,  an  operation  which  the  practitioner  will  need  to  perform 
scores  of  times  before  he  sews  up  a  lacerated  cervix.  The  curette  is  men- 
tioned in  a  succeeding  chapter  in  connection  with  growths  from  the  inter- 
nal uterine  surface.  It  receives  only  condemnation,  which  could  but  be 
expected,  from  the  author's  views  as  to  intra-uterine  applications  of  all 
kinds.  In  this  condemnation  of  the  curette  we  wish  Dr.  Emmet  had 
stated  why  the  original  instrument  of  Reeamier  "  has  proved  a  most  ob- 
jectionable one."  It  has  not  the  cutting  edge  of  the  instruments  of  Simp- 
son, Sims,  and  Simon,  it  is  as  blunt  as  Thomas's  wire  loop,  and,  in  our 
opinion,  the  original  instrument  has  never  been  improved  upon.  It  is  to 
be  regretted  that  it  is  not  to  be  found  at  our  instrument-makers. 

These  deficiencies  of  consideration  of  certain  subjects  come  naturally 
from  the  position  occupied  by  the  author.  He  whose  practice  is  bounded 
by  the  walls  of  a  hospital  sees  many  and  severe  cases  which  well  fit  him 
to  be  a  teacher  of  the  profession,  but  he  is  too  apt  to  overlook  those  phases 
of  disease  which  in  general  practice,  and  especially  to  the  young  practi- 
tioner, are  matters  of  great  importance  and  of  very  frequent  occurrence. 

There  are  some  omissions  of  importance  scarcely  to  be  expected  in  a 
work  so  certain  to  be  turned  to  for  reference.  Thus,  in  regard  to  amputa- 
tion of  the  inverted  uterus,  it  is  to  be  regretted  that  the  author  has  not  in- 
corporated statistics  of  the  mortality  of  the  operation  later  than  those  of 
Schroeder  and  Ziemssen's  Hand-book,  or  those  published  in  the  American 
Journal  of  Obstetrics  for  1868.  True,  it  is  an  operation  which  the  author 
does  not  sanction  ;  still  the  highest  authorities  agree  that  it  must  some- 
times be  performed.  If  done,  the  best  results  have  been  obtained  by  the 
elastic  ligature,  the  mortality  being  less  than  by  the  wire  gradually  tight- 
ened, which  is  here  stated  to  be  the  best,  while  the  elastic  ligature  is  not 
even  mentioned,  although  introduced  by  Courty  in  1 874,  and  in  his  last 
edition,  1881,  is  stated  to  be  beyond  comparison  the  most  effective  and 
the  safest  measure.  Nor  are  attempts  at  reduction  so  void  of  clanger  as 
here  stated.    Denuce  gives  the  mortality  at  10  per  cent,  in  cases  of  reduc- 


1885.]     Emmet,  Principles  and  Practice  of  Gynaecology. 


499 


tion  before  involution,  and  6  per  cent,  afterwards,  while  in  the  reduction 
of  recent  cases  it  is  as  high  as  18  per  cent.1 

The  work  of  Dr.  Emmet  having  reached  the  stage  of  existence  indi- 
cated by  a  third  edition,  an  inquiry  as  to  the  influence  it  has  exerted,  and 
that  it  will  exert,  especially  upon  the  younger  members  of  the  profession 
is  legitimate.  In  some  respects  it  will  be  markedly  for  good.  Its  admo- 
nitions of  caution  in  interfering  with  the  uterus  in  some  ways,  its  inculca- 
tion of  the  necessity  of  the  closest  attention  to  details,  its  directions  for 
absolute  cleanliness,  its  reiteration  of  the  necessity  of  searching  for  and 
duly  considering  extra-uterine  inflammation,  cannot  but  be  beneficial. 
There  are  other  directions,  however,  to  be  considered.  When  we  read 
the  lament  (p.  648)  that 

"  There  are  more  men  in  the  country  to-day  who  would  seize  the  first  oppor- 
tunity presenting  to  get  out  an  ovarian  tumor,  or  an  ovary,  than  there  were  thirty 
years  ago,  who  would  have  been  willing  to  cut  a  tonsil." 

The  "queries  immediately  arise,  Whom  have  we  to  thank  for  this  state 
of  affairs  ?  If  complicated,  not  to  say  fantastic,  operations  are  devised  and 
taught  to  be  necessary  for  lesions  of  every-day  occurrence,  is  it  surprising 
that  enterprising  and  ambitious  men  will  undertake  other  operations  far 
simpler  in  detail  and  execution  ? 

Farther,  will  this  book  prove  to  be  the  foundation  of  a  "  school"  of 
gynaecology,  as  is  more  than  hinted  in  the  preface  ?  Its  doctrines  are  pro- 
mulgated with  energy  and  with  a  positiveness  verging  on  dogmatism. 
They  are  based  upon  clinical  observation,  and  command  respect  from  even 
those  who  reject  them.  They  concern  many  points  which  are  not  yet 
fully  understood,  and  upon  which  different  opinions  are  held  by  equally 
competent  observers,  and  as  a  multiplicity  of  remedies  surely  indicates 
the  incurability  of  a  disease,  so  surely  does  diversity  of  opinion  show  that 
the  truth  has  not  yet  been  attained.  Time  alone  can  answer  the  query 
propounded.  Meantime,  we  hazard  the  prediction  that  when  an  enduring 
school  of  gynaecology  shall  appear,  its  foundations  will  be  in  harmony 
with  the  doctrines  of  general  pathology,  its  elements  will  extend  beyond 
the  affections  of  single  tissues  or  organs,  and  it  will  be  built  by  one  who 
can  hold  with  a  steady  hand  the  balance  in  which  is  determined  with 
precision  the  relative  value  of  surgical  and  medical  measures  of  treatment. 

If  in  this  notice  attention  has  been  called  to  a  number  of  points  which 
could  not  be  spoken  of  in  terms  of  laudation,  we  maintain  that  we  are  not 
inconsistent.  No  jot  or  tittle  of  the  high  praise  bestowed  upon  the  first 
edition  is  abated.  It  is  still  a  book  of  marked  personality,  one  based  upon 
large  clinical  experience,  containing  large  and  valuable  additions  to  our 
knowledge,  evidently  written  not  only  with  honesty  of  purpose,  but  with 
a  conscientious  sense  of  responsibility,  and  a  book  that  is  at  once  a  credit, 
to  its  author  and  to  American  medical  literature.  We  repeat  that  it  is  a 
book  to  be  studied,  rather  than  read,  and  one  that  is  indispensable  to  every 
practitioner  giving  any  attention  to  gynaecology.  J.  C.  R. 


1  Traite  Clinique  de  l'Inversion  Uterine.    Paris,  1883. 


500 


Reviews. 


[April 


Art.  XIX  Latest  Porro- C&sarean  Statistics,  with  an  Analysis  of 

all  the  Cases. 

1.  "  Porro' s  Operation:  A  Supplement.  By  Clement  Godson,  M.D., 
Consulting  Physician  to  the  City  of  London  Lying-in  Hospital,"  etc., 
being  a  continuation  of  the  record  published  in  the  British  Medical 
Journal  of  January  26th,  1884.  Ibid.  Jan.  17th,  1885,  pages  120-122. 

2.  Sulla  Operazione  Porro.  Siudia  critico-statistico,  del  Truzzi 
Ettore.  1°.  Assistente  presso  la  R.  Scuola  pareggiata  di  Ostetricia 
in  Milano.  (Annali  JJniversali  di  Medicina  e  Chirurgia,  vol.  269. 
Ottobre,  1884,  pp.  387-394.    Novembre,  1884,  pp.  401-428.) 

The  Porro  Operation,  a  Critico- Statistical  Study.  By  Ettore  Truzzi, 
First  Assistant  of  the  Royal  Obstetrical  School  of  Milan. 

Dr.  Godson  has  added  fifteen  cases  to  his  former  table  of  137,  making 
it  152,  but  appears  not  to  have  seen  the  two  numbers  of  the  Annali, 
issued  in  October  and  November,  in  which  Dr.  Truzzi  gave*  twelve 
additional,  that  he  obtained  mainly  by  correspondence  with  the  operators, 
making  in  all  164  cases.  Both  of  these  writers  have  once,  and  with 
success  to  mother  and  child,  performed  the  operation,  and  that  of  the 
former  is  the  only  one  not  fatal  in  England,  in  the  cases  where  the  foetus 
was  developed  to  a  viable  age.  Dr.  Truzzi  is  the  successor  of  Dr. 
Mangiagalli  (whose  Porro  record  was  noticed  in  this  journal,  and  Avho  is 
now  a  Professor  in  the  Royal  Medical  School  of  Sassari,  in  the  island  of 
Sardinia)  ;  and  enjoys  the  advantage  of  being  the  associate  of  Prof. 
Porro  himself.  It  is  much  to  the  credit  of  the  three  junior  members  of 
the  staff  of  Santa  Caterina  that  they  have  operated  upon  four  women 
without  losing;  one  ;  one  of  them  having  had  two  cases.  When  we  recall 
the  number  of  Cesarean  operations  that  have  in  the  past  been  performed 
in  the  same  hospital,  and  their  frightful  mortality,  wre  can  appreciate  the 
change  effected  by  the  improvement  of  Porro,  and  the  confidence  with 
which  it  is  performed.  In  no  hospital  in  the  world  is  greater  care  exer- 
cised to  insure  success,  and  the  time  of  operating  has  been  reduced  to 
from  twenty-five  to  forty  minutes.  In  one  European  operation,  two  hours 
are  said  to  have  been  consumed,  and  another  is  claimed  to  have  required 
but  fifteen  minutes. 

One  of  the  advantages  gained  by  the  removal  of  the  uterus  and 
ovaries  is,  that  it  will  undoubtedly  cure  malacosteon.  This  I  have  upon 
the  authority  of  the  letters  of  several  operators,  whose  patients  have 
recovered  after  having  been  crippled  and  bedridden.  It  is  thought 
essential,  to  effect  an  early  cure,  that  the  woman  should  not  nurse  her 
infant,  and  it  has  been  proposed  by  Dr.  Fehling,  whose  three  malacostean 
women  were  cured,  to  perform  Battey's  operation  as  a  means  of  arresting 
this  bone  disease.  As  it  is  his  expectation  to  make  trial  of  this  process 
when  he  has  a  suitable  case,  wre  shall  no  doubt  hear  in  time  of  the  result 
of  the  experiment :  it  is  certainly  one  that  promises  success  in  some 
cases. 


1885.] 


Latest  Porro- Cesarean  Statistics. 


501 


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Result 
to  child. 

Living 
Dead 
Living 

Living- 
Dead 
Living 

it 

Dead 
Living 

t  i 
it 

Dead 

Result  to 
woman. 

Died 

Recovered 

Died 
Recovered 

Died 

it 

Recovered 
Died 

Recovered 

Died 
Recovered 

Died 

Locality  of 
operation. 

Lyons,  France 

Stuttgart,  Ger. 
Freibourg  " 
Vienna,  Aust. 
Stuttgart,  Ger. 
Turin,  Italy 
Edinburgh,  Scot. 
London,  Eng. 

Vienna,  Aust. 
Vigevano,  Italy 
Paris,  France 
Sarcento,  Italy 
Leipzig,  Ger. 
Bergamo,  Italy 

Como,  " 
Milan,  " 
Prague,  Aust. 
Vienna,  " 
Florence,  Italy 

Pavia,  " 
Naples,  " 
Siena,  " 
London,  Eng. 
Imola,  Italy 

Breslau,  Ger. 

London,  Eng. 

Name  of  operator. 

Dr.  Laroyenne 

"  Fochier 

"    H.  Fehling 
Prof.  A.  Hegar 

"  Spiith 
Dr.  II .  Fehling 
Prof.  Tibone 

"    A.  Simpson 
Dr.  Herman 

Prof.  G.  Braun 
Dr.  Cuzzi 
Prof.  L.  Dumas 
Dr.  Franzolini 
Prof.'  Sanger 
Dr.  Ulietti 

"  Comolli 
"  Truzzi 
Prof.  A.  Breisky 
"  Spath 
"  Chiara 

Dr.  Guzzoni 
Prof.  R.  Novi 
Dr.  E.  Falaschi 
"    F.  Barnes 
"    Vincenzo  Lesi 

Prof.  Fritsch 

Dr.  Handfleld  Jones 

Date  of 
operation. 

March,  1880 
Nov.  " 
Oct.  11,  1883 
Dec.  25,  " 
Jan.    9,  1884 
"     26,  " 
"     30,  " 
"     30,  " 
Feb.  14,  " 

»     15,  « 
"     20,  " 
April  10,  " 
May    2,  " 

June  10,  " 
»  10,  « 
"  25,  " 
"     28,  " 

July  15,  " 

"  -23,  " 
•  "     23,  " 
Aug.  15,  " 
Sept.  11,  " 
Oct.  23,  " 

Nov.  13,  " 

Dec.    2,  " 

Nos. 
con- 
tinued. 

OOOiO^HOJCO-^iCCD      NOO  OS  Ci  r-l           CO       lO  JO  J>       QOOOHN       CO  -+-' 
CCn^TjH^tHT^^^TX           ■+       lO  «  O                                   o  ia  O  CO  CO       co  o 
HrlrlHHHHrtn  HHr It-It— i  r-l       rlHrlrl-H        r-l  r-l  r-l  rM  r-l        r-l  r-H 

502 


Reviews. 


[April 


Operations  in  different  Countries,  not  including  those  performed  before 
the  Foetus  was  viable,  which  are  placed  in  Class  2. 

Italy  .       .  43  operators  ;  65  operations.  Women  saved,  28  ;  percentage,  43| 

Austria       .     9       "  34        "  "  "     20  "  58H 

Germany     .  16       "  28        "  "         "       9  "  32f 

France              7       "  15        "  u  "       5  "  33A 

Great  Britain     8       "  9        "  "  11       1  "  Hi 

United  States    3       "  3        lc  "  "       1  "  33i 

Besides  the  above,  there  were  a  few  operations  performed  in  each  of 
several  other  countries,  viz.,  in  Belgium  four,  saving  two  women ;  in 
Switzerland  two,  both  saved ;  in  Holland  one,  saved ;  in  Russia,  one, 
saved;  and  in  Spain  one,  lost. 

General  Summary — The  average  number  of  operations  per  annum  is 
now  about  25.  There  were  33  in  1880  ;  21  in  1881  ;  25  in  1882  ;  22  in 
1883  ;  and  as  far  as  ascertained  23  in  1884.  Of  the  164  cases  recorded, 
many  of  which  are  not  yet  published  by  the  operators,  the  Porro  method, 
unmodified,  was  employed  in  109  cases,  many  of  them  very  unfavorable, 
with  46  recoveries.  Mtiller's  modification  was  used,  without  the  experi- 
mental addition  of  Veit,  in  41  cases,  with  21  recoveries.  Veit's  addition 
of  dropping  in  the  pedicle  (stump)  was  tried  in  completing  both  forms  of 
operation,  in  14  cases,  with  only  4  recoveries.  This  is  a  very  inviting 
process,  but  far  more  fatal  than  where  the  stump  is  treated  by  the  extra- 
peritoneal method.  In  six  instances  the  Miiller  method  of  turning  out 
the  uterus,  after  making  the  long  abdominal  incision,  was  abandoned,  and 
the  cases  managed  by  the  Porro  plan  ;  of  these  6,  4  were  saved.  From 
the  164  women,  166  children  were  extracted,  two  bearing  twins;  of 
these  129  were  "  living,"  but  not  moribund,  and  37  were  dead  or 
moribund.  The  Italian  operators  saved  53  children,  and  lost  13;  the 
German  18,  and  lost  10;  the  Austrian  32,  and  lost  3;  the  French  10, 
and  lost  5  ;  the  English  and  Scotch  6,  and  lost  3  ;  the  United  States  2,  and 
lost  1 ;  and  the  Belgian  and  Swiss  saved  all  delivered,  i.  <?.,  4  and  2  respec- 
tively. 

In  the  Krankenhaus  of  Vienna,  under  five  operators,  there  have  been 
26  operations,  saving  13  women  and  23  children  ;  in  3  of  the  fatal  cases 
the  stump  was  ligated  and  dropped  in.  In  Santa  Caterina  Maternity,  of 
Milan,  also  under  five  operators,  there  have  been  13  operations,  saving  10 
women  and  13  children.  The  Miiller  modification  has  been  used  but 
once,  and  in  case  2,  which  proved  fatal.  The  first  and  second  operations 
were  fatal,  as  was  also  the  ninth,  which  last  died  of  strangulation  of  the 
bowels.  The  Miiller  modification  has  only  been  used  7  times  in  Italy, 
saving  3  women. 

In  calculating  the  risks  of  the  Porro-Csesarean  section,  as  founded 
upon  its  statistics,  I  think  it  but  just  to  the  originator  to  reduce  the  164 
operations  to  147,  by  excluding  3  moribund  cases  operated  upon  to  save 
the  children,  and  14  in  which  the  stump  was  dropped  in,  proving  fatal  in 
10.  This  will  reduce  the  number  of  women  recovered  to  65,  and  give  a 
percentage  of  44  women  saved.  Of  the  147,  there  were  90  cases 
regarded  as  u favorable,"  " fair,"  oy  "  not  unfavorable"  for  the  opera- 
tion, and  of  these  53  recovered  and  37  died.  There  were  also  57,  rated 
as  "  unfavorable,"  "  very  unfavorable,"  u  deplorable,"  etc.,  of  which  13 
recovered  and  44  died.  As  a  hospital  operation,  particularly  when  the 
patient  is  prepared  beforehand,  and  the  time  carefully  selected,  the 
results  have  been  very  encouraging,  as  shown  by  the  Milan  record  above. 


1885.] 


Latest  Porro- Caesarean  Statistics. 


503 


Prof.  Breisky,  of  Prague,  has  saved  all  five  of  his  patients  in  hospital  ; 
Prof.  Porro,  of  Milan,  4  out  of  5  ;  and  Dr.  Fehling,  of  Stuttgart,  4  out 
of  5.  Prof.  Carl  Braun,  of  Vienna,  saved  8  out  of  12,  losing  one  in 
which  he  dropped  in  the  stump.  The  cases  operated  upon  in  private 
houses  number  only  23,  of  which  10  recovered  and  13  died,  showing  no 
special  advantage  over  those  in  hospital.  The  best  record  of  any  country, 
it  will  be  noticed,  is  that  of  Austria,  where  the  operators  averaged  nearly 
4  cases  each,  and  would  no  doubt  have  saved  over  60  per  cent,  but  for 
the  fatal  results  in  Vienna  of  dropping  in  the  stump,  in  three  cases.  Of 
8  cases  not  operated  upon  in  Vienna,  7  were  saved,  by  four  operators. 
In  Germany,  nearly  one-half  of  the  cases  saved  (4  out  of  9)  were  by 
one  operator,  whose  success  amounted  to  80  per  cent.  ;  the  other  15 
operators  saved  but  5  out  of  23  ;  hence  the  efforts  made  to  revive  and 
diminish  the  mortality  of  the  old  operation,  on  the  part  of  Sanger, 
Kehrer,  Leopold,  and  other  Germans.  Great  Britain  as  yet,  like  our 
own  country,  has  had  but  one  success,  and  her  average  is  even  lower  than 
by  the  old  operation.  Dr.  Godson  has  his  honor  undivided  thus  far  by 
any  one,  although  six  others  have  operated  since  the  date  of  his  success. 
Laparo-elytrotomy  failed  also  twice,  although  6  out  of  10  have  been 
successful  in  this  country. 

The  English  subject  appears,  from  all  the  tests  that  have  been  made, 
under  what  otherwise  should  be  favorable  circumstances,  to  be  a  very  bad 
one  for  abdominal  delivery,  although  ovariotomies  have  been  remarkably 
successful.  Rickets  and  malacosteon  appear,  much  more  than  cancer,  to 
be  predisposing  causes  of  failure,  and  when  poverty,  with  its  starvation, 
and  intemperance  are  superadded,  there  is  very  little  to  encourage  an 
operator  in  making  his  prognosis.  Success  in  the  Porro  operation  is  in  a 
degree  national,  and  depends  for  its  greatness,  not  only  upon  care,  skill, 
and  promptness,  but  very  much,  also,  upon  the  subject  of  it. 

Delay  in  operating  was  long  believed  to  be  the  foundation  of  ill-success 
in  Great  Britain,  in  the  old  Cesarean  section  ;  but  this  plea  is  no  longer 
tenable,  since  *t  has  been  shown  by  33  cases  that  early  operating  has 
saved  but  25  per  cent.  In  eleven  of  these  cases  labor  lasted  from  2  to  10 
hours,  8  children  were  saved,  but  all  of  the  women  perished.  In  the 
United  States,  the  number  of  cases  in  which  the  time  is  noted  in  hours, 
from  2  to  10  inclusive,  amounts  to  13  :  of  6  "favorable"  cases,  5  recov- 
ered ;  of  5  "unfavorable,"  1  recovered;  and  of  2  "very  unfavorable," 
1  recovered,  making  7  women  saved  out  of  13,  with  9  children  :  five  of  the 
women  were  dwarfs,  of  whom  three  recovered.  Of  cases  in  the  United 
States,  in  which  the  measure  of  time  in  labor  is  designated  by  the  expres- 
sions "  short"  "  early  "  "  a  few  hours,"  and  "  several  hours,"  I  find  9, 
with  4  recoveries,  and  9  children  saved.  The  term  "  early"  is  a  very 
unsatisfactory  one,  being  at  best  only  relative  :  six  or  eight  hours  would 
not  be  early, in  a  dwarf  of  3  feet  4  inches  in  height,  and  65  pounds  weight, 
as  was  one  in  this  list  of  nine.  As  there  were  25  children  saved,  by  the 
33  British  operations,  it  is  to  be  presumed  that  the  cases  were  of  an  ave- 
rage character.  Three  cases  were  not  in  labor  ;  in  another  it  was  induced, 
and  no  case  exceeded  18  hours.  In  17  women,  the  time  ranged  from 
0  to  10  hours,  saving  but  4  of  them  ;  and  in  16  more  it  ranged  from  11  to 
18  hours  inclusive,  saving  also  4  ;  total,  8. 

With  the  exceptions  of  Denmark,  Norway,  and  Sweden,  I  know  of  no 
country  in  which  the  Ca3sarean  operation  has  been  more  fatal  than  in 
Great  Britain.    Like  it,  the  Porro  operation  is  largely  dependent  for  sue- 


504 


Reviews  . 


[April 


cess  upon  the  condition  of  the  patient  at  the  time  it  is  performed.  This 
is  very  clearly  established  by  the  record  already  analyzed.  If,  then,  a 
timely  elective  and  prearranged  Cgesarean  operation  must  have  an  unfavor- 
able prognosis  because  of  the  physical  condition  and  poverty  of  the  sub- 
ject, can  much  more  be  anticipated  from  the  Porro  improvement  under 
the  same  disadvantages?  Laparo-elytrotomy,  which  has  been  tried,  but 
not  tested  under  favorable  circumstances  in  England,  may  prove  less  fatal 
than  either,  as  it  neither  wounds  the  uterus  nor  opens  the  peritoneal  cavity. 

Class  2  In  this  division  Dr.  Godson  has  placed  the  less  fatal  opera- 
tions of  removal  of  the  uterus  and  ovaries  in  cases  where  the  foetus  was 
not  yet  viable.  These  operations  now  number  10,  with  7  women  saved. 
Eight  cases  were  affected  with  uterine  fibro-myoma,  one  with  vaginal 
occlusion,  and  in  one  the  uterus  had  been  punctured  in  error,  in  perform- 
ing ovariotomy  in  Australia.  Twice  has  this  accident  happened  and  been 
treated  successfully  by  the  Cassarean  operation,  under  Dr.  Byford  and  Sir 
T.  Spencer  Wells;  and  although  the  Australian  case  recovered,  it  left  a 
primipara  of  21,  without  uterus  or  ovaries,  because  of  an  error  of  the  ope- 
rator in  using  his  trocar.  We  believe  this  is  carrying  the  Porro  mutila- 
tion to  an  unjustifiable  degree. 

Glass  3  Prevot's  Application — This  Moscow  process  of  treating  the 

uterus  after  it  has  been  ruptured,  by  amputating  it  after  the  Porro  method, 
has  now  been  tried  seven  times,  and  all  of  the  women  have  perished,  viz  : 
one  each  in  Russia,  Germany,  France,  and  England,  and  three  in  Italy. 
We  see  nothing  to  recommend  this  plan  over  the  much  less  fatal  one  of 
closing  the  uterine  rent  by  sutures  ;  neither  do  we  find  anything  to  justify 
the  mutilation  where  there  is  no  pelvic  deformity.  The  new  method  of 
closing  the  uterus  in  the  Cesarean  operation  by  deep  and  superficial 
sutures,  with  the  peritoneum  turned  in,  can  be  applied  after  laparotomy 
and  cleansing  to  a  uterine  rent  with  fair  promise  of  success,  as  many  cases 
have  recovered  without  suturing.  But  to  secure  a  strong  union,  and  guard 
against  a  repetition  of  the  accident,  we  believe  there  is  better  safety  in  the 
suture.  Quite  recently  we  noticed  the  advocacy  of  Prevot's  method  before 
a  society  in  New  York  ;  but  its  measure  of  fatality,  we  presume,  could  not 
have  been  known. 

Glass  4. — Among  the  operations  called  Porro,  have  been  three,  in  which 
one  cornu  of  a  bifid  uterus  with  its  ovary  has  been  removed,  together  with 
a  dead  foetus  within  the  cornu.  Of  these  cases  two  recovered.  In  that  of 
Sanger,  of  Leipzig,  the  cornu  was  ligated,  and  the  peritoneum  stitched 
over  it  with  eight  sutures,  after  which  it  was  dropped  in  ;  the  woman 
recovered.  R.  P.  H. 


Art.  XX  A  Practical  Treatise  on  Disease  in  Children.    By  Eustace 

Smith,  M.D.,  F.R.C.P.  Lond.,  Physician  to  His  Majesty  the  King 
of  the  Belgians,  Physician  to  the  East  London  Children's  Hospital, 
and  to  the  Victoria  Park  Hospital  for  Diseases  of  the  Chest.  8vo.  pp. 
844.    New  York  :  William  Wood  &  Co.,  1884. 

Dr.  Eustace  Smith  is  already  favorably  known  to  the  American  profes- 
sion as  a  frequent  contributor  to  the  English  medical  journals,  and  as  the 


1885.] 


Smith,  Diseases  of  Children. 


505 


author  of  an  excellent  Manual  on  The  Wasting  Diseases  of  Infants  and 
Children,  which  has  recently  passed  into  its  fourth  edition. 

From  the  preface  we  learn  that  the  present  book  was  prepared  on  the 
invitation  of  Messrs.  Wood  &  Co.,  of  New  York,  "  to  write  for  them  a 
Complete  Treatise  on  the  Diseases  of  Infancy  and  Childhood."  If  the 
publishers  were  compelled  to  cross  the  Atlantic  in  search  of  an  acceptable 
author,  they  showed  good  judgment  in  the  selection  of  Dr.  Smith,  whose 
long  official  connection  with  the  East  London  Children's  Hospital  has 
given  him  exceptional  opportunities  for  the  study  of  the  diseases  of  early 
life.  Dr.  Smith  has  not  only  given,  in  the  volume  before  us,  the  fruits  of 
his  own  rich  clinical  experience,  but  almost  every  page  bears  tangible  evi- 
dence of  his  familiarity  with  current  pediatric  literature.  The  excellent 
work  done  in  this  department  of  medicine  by  American  authors  is  duly 
recognized  by  numerous  references  in  the  text. 

The  author  undertakes  to  discuss  from  a  clinical  standpoint  the  whole 
subject  of  disease  in  early  life,  and  has  therefore  admitted  to  his  pages 
"  descriptions  of  every  form  of  illness  which  is  influenced  in  its  manifesta- 
tions by  the  early  age  of  the  patient.  Those  only  have  been  purposely 
omitted  which,  like  diabetes,  present  exactly  the  same  characters  in  the 
child  that  they  do  in  the  adult."  This  fact  gives  to  Dr.  Smith's  Treatise 
a  completeness  enjoyed  by  but  few  of  the  many  excellent  works  on  Pedi- 
atrics now  before  the  profession.  The  author's  claim  to  completeness  can 
not,  however,  be  fully  sustained. 

While  it  may  be  perfectly  proper  to  consider  at  length  such  rare  mala- 
dies as  scurvy,  hydatids  of  the  liver,  cirrhosis,  megrim,  etc.,  the  omission 
of  a  chapter  on  a  disease  so  frequent  and  dangerous  as  ophthalmia  neonato- 
rum is  a  matter  of  regret,  and  appears  inexcusable  in  a  treatise  aspiring  to 
be  complete.  Issuing  from  an  American  publishing  house  the  inference 
is  that  the  work  is  designed  especially  for  American  students  ;  if  so,  it 
would  be  better  were  the  prescriptions  compounded  according  to  our  Phar- 
macopoeia. The  British  Pharmacopoeia  is  used,  and  unless  this  fact  is 
borne  in  mind  unpleasant  effects  may  follow  the  administration  of  some  of 
the  doses  recommended.  For  example,  Dr.  Smith  gives  ten  drops  of  the 
tincture  of  belladonna  to  a  newly  born  infant,  and  twenty  or  more  drops  to 
a  child  one  year  old,  but  the  author  is  speaking  of  the  tincture  of  the  B. 
P.,  which  is  only  about  one-half  the  strength  of  that  of  the  U.  S.  P. 

The  introductory  chapter  with  which  the  book  opens  deals  with  the  pe- 
culiarities of  disease  as  it  occurs  in  children,  the  effects  of  the  various 
diatheses,  the  predominant  influence  of  the  nervous  system,  the  proper 
methods  of  examination,  general  consideration  upon  therapeutics  and 
kindred  subjects.    The  fact  is  strongly  emphasized  that 

"  Children  are  not  merely  little  men  and  women  in  whose  bodies  disease  mani- 
fests itself  by  exactly  the  same  tokens  that  are  familiar  to  us  in  the  ease  of  the 
adult.  They  have  special  constitutional  peculiarities  which  give  to  disease  in 
early  life  a  character  it  does  not  afterwards  retain,  and  invest  the  commonest 
forms  of  illness  with  strange  features  which  may  be  a  source  of  obscurity  and 
confusion." 

He  who  masters  this  chapter  will  have  taken  a  long  stride  in  the  suc- 
cessful management  of  the  diseases  of  the  nursery. 

The  subject-matter  of  the  volume  is  arranged  in  twelve  parts. 

Part  I.  is  devoted  to  the  acute  infectious  diseases.  The  group  of  erup- 
tive fevers  receives  the  attention  which  its  importance  and  frequency 
demand.    The  clinical  pictures  are  sharply  drawn,  and-  the  treatment 


506 


Reviews. 


[April 


recommended  is  essentially  that  of  the  latest  authorities.  In  speaking  of 
the  prophylaxis  of  scarlet  fever  the  following  statement  is  made,  which,  if 
corroborated  by  subsequent  observation,  will  mark  an  important  advance 
in  the  management  of  epidemics  : — 

"Belladonna,  which  was  at  one  time  largely  employed  with  this  object,  has 
been  now  proved  to  be  useless.  It  seems  likely,  however,  that  in  arsenic  we  have 
an  agent  of  greater  value.  It  has  been  noticed  that  a  person  who  is  being  treated 
with  arsenic  cannot  be  successfully  vaccinated,  and  it  is  possible  that  the  drug 
may  have  a  counteracting  influence  upon  other  forms  of  infective  matter.  Prac- 
titioners who  have  made  use  of  the  remedy  with  this  object  speak  favorably  of 
its  prophylactic  virtue.  Dr.  W.  G.  Walford  has  given  the  drug  largely  to 
children  who  had  been  exposed  to  the  infection  of  scarlatina,  and  states  that  out 
of  nearly  a  hundred  such  cases  in  only  two  did  the  development  of  the  fever 
follow,  and  both  cases  were  extremely  mild.  He  recommends  the  ordinary  liq. 
arsenicalis  (P.  B.)  in  as  large  a  dose  as  the  age  of  the  child  will  allow,  with  sul- 
phurous acid  (TTt  xv-xxx),  and  a  little  syrup  of  poppy.  The  child  should  take 
the  dose  regularly  three  times  a  day  at  the  first ;  afterwards  less  frequently." 

The  statement  that  arsenic  will  prevent  successful  vaccination  cannot 
be  accepted  as  absolutely  correct,  since  the  writer  has,  within  the  past 
year,  successfully  vaccinated  a  child  whose  system  was  thoroughly  under 
the  influence  of  that  drug,  given  for  an  eczema. 

The  author  is  not  fully  in  accord  with  the  doctrine  that  the  specific  dis- 
eases are  caused  by  micro-organisms.  He  does  not  even  allude  to  the  re- 
cent researches  of  Prof.  Eklund  and  others  as  to  the  parasitic  nature  of 
scarlatina,  and  in  speaking  of  diphtheria  holds  the  following  language  : — 

"Diphtheria  is  no  doubt  the  consequence  of  a  specific  poison,  however  this 
may  originate.  The  essence  of  the  disease  has  been  attributed  to  spherical 
bacteria  (micrococci),  which  have  been  discovered  swarming  in  the  false  mem- 
branes and  exudations  from  the  inflamed  mucous  surfaces  ;  but  as  similar  bacteria 
have  been  found  in  the  secretions  thrown  out  by  ordinary  non-specific  stomatitis, 
too  much  importance  must  not  be  attributed  to  the  presence  of  these  organisms. 
The  real  nature  of  the  virus  has  yet  to  be  discovered." 

Dr.  Smith,  while  questioning  the  absolute  identity  of  membranous 
croup  and  laryngeal  diphtheria,  considers  a  very  large  proportion  of  the 
croup  cases  to  be  diphtheritic  in  nature  :  he  does  not  assign  a  special  chap- 
ter to  the  discussion  of  true  croup.  After  fully  restating  the  customary 
arguments,  pro  and  con,  he  sums  up  as  follows  : — 

"  From  consideration  of  the  above  facts  and  arguments  the  only  conclusion  to 
be  drawn  is  that  a  large  proportion  of  cases  of  membranous  croup  are  cases  of 
laryngeal  diphtheria.  It  does  not,  however,  follow  that  membranous  laryngitis 
is  never  due  to  any  other  cause  than  the  diphtheritic  poison.  The  child's  larynx 
is  especially  prone  to  membranous  inflammation  ;  and  if,  as  has  been  positively 
stated,  a  true  false  membrane  may  be  set  up  by  burns,  scalds,  and  other  irritant? 
to  the  air-passages,  it  is  possible  that  the  disease  may  occasionally  occur  inde- 
pendently of  the  diphtheritic  virus." 

There  is  no  allusion  to  mercury  in  the  treatment  of  this  disease ;  an 
omission  which,  in  view  of  the  very  favorable  reports  made  during  the 
past  three  years  of  the  internal  administration  of  the  bichloride,  especially 
in  the  laryngeal  form  of  the  disease,  is  hardly  pardonable.  There  is  cer- 
tainly no  other  treatment  in  vogue  to-day  which  has  given  as  satisfactory 
results.  The  author  is  an  ardent  advocate  of  operative  interference  when 
the  disease  (diphtheria)  invades  the  larynx  : — 


1885.] 


Smith,  Diseases  of  Children. 


507 


"Directly,  therefore,  we  feel  sure  the  larynx  is  involved,  the  operation  should 

be  undertaken  without  delay  The  success  which  often  attends  the 

operation  of  tracheotomy  in  membranous  croup  is  very  encouraging,  and  even  in 
the  case  of  infants  we  should  not  hesitate  to  have  recourse  to  it." 

Dr.  Smith  does  not  give  any  statistics,  but  it  seems  to  us  he  speaks  too 
discouragingly  of  the  constitutional  treatment  of  laryngeal  diphtheria,  and 
too  confidently  of  the  good  results  to  be  obtained  from  tracheotomy.  Dr. 
Jacobi,  in  his  latest  utterance  upon  this  subject,  in  which  he  is  a  recog- 
nized authority,  says  : — 

"  Tracheotomy  saves  but  few  of  those  who  take  the  disease  in  severe  epidemics. 
In  fifty  consecutive  tracheotomies,  from  1872  to  1874,  I  did  not  see  one  recovery. 
In  the  last  few  years  I  have  seen  few  good  results.  In  average  epidemics  trache- 
otomy will  save  twenty  per  cent."  (American  Sys.  of  Medicine,  Art.  Diph- 
theria, p.  692.) 

Parts  II.  and  III.  include  the  non-infectious,  general,  and  diathetic 
diseases,  the  most  important  chapters  being  devoted  to  Rickets,  Rheuma- 
tism, Scrofula,  and  Syphilis.  The  chapter  on  Syphilis  is  especially  full 
and  exhaustive. 

Part  V.,  consisting  of  nineteen  chapters,  is  devoted  to  a  consideration 
of  the  diseases  of  the  nervous  system.  The  chapter  on  Convulsions  is  full 
of  practical  hints  drawn  from  the  author's  experience.  We  regret,  how- 
ever, that  he  has  omitted  from  his  list  of  causes  any  reference  to  preputial 
irritation.  From  our  own  observation  we  are  convinced  that  it  is  by  no 
means  a  rare  cause  of  convulsive  seizures  in  male  infants,  and  have  more 
than  once  seen  circumcision  prove  effectual  in  breaking  up  the  eclamptic 
habit.  In  speaking  of  the  influence  of  lead-poisoning  in  causing  convulsive 
attacks,  he  says  : — 

"  Infants  seem  to  be  very  susceptible  to  the  influence  of  lead  given  medicinally. 
I  have  long  ceased  to  make  use  of  this  remedy  in  the  treatment  of  the  diarrhoeas 
of  young  children,  as  I  have  several  times  seen  convulsions  follow  its  employment, 
and  the  attacks  have  appeared  to  me  in  some  cases  to  be  directly  excited  by  the 
use  of  this  agent." 

He  speaks  highly  of  the  nitrite  of  amyl  in  arresting  convulsions,  and 
uses  it  without  fear  of  danger  in  young  children.  The  remedy  may  be 
given  by  the  mouth  or  by  inhalation.  To  infants,  six  or  nine  months  old, 
one-quarter  of  a  drop  may  be  given  in  mucilage  three  or  four  times  a  day  : 
the  inhalation  of  a  single  drop  will  often  speedily  arrest  an  eclamptic  seiz- 
ure, even  when  dependent  upon  cerebral  disease.  The  chapters  on  Tuber- 
cular Meningitis  and  Chorea  are  exceptionally  good.  The  author  is  a  firm 
believer  in  the  value  of  arsenic  in  chorea  : — 

"  Of  all  the  drugs  which  have  been  recommended  as  specifics  in  this  complaint 
the  only  one  from  which  I  have  ever  seen  any  decided  benefit  has  been  arsenic, 
and  with  this  only  in  large  doses  I  have  been  in  the  habit  of  pre- 
scribing for  a  child  of  five  or  six  years  of  age  ten  drops  of  Fowler's  solution  of 
arsenic,  directly  after  meals,  three  times  a  day.  In  this  dose  it  is  rarely  found  to 
disagree.  If  the  child  complain  of  discomfort  at  the  epigastrium,  and  vomit  a 
short  time  after  taking  the  remedy — and  these  are  the  only  unpleasant  symptoms 
I  have  known  the  medicine  to  produce — it  can  be  given  for  a  time  twice  a  day  or 
in  smaller  doses.  In  every  case  the  dose  should  be  as  large  a  one  as  can  be  borne 
without  discomfort,  and  given  thus  immediate  benefit  will  usually  ensue." 

One  hundred  and  five  pages  are  set  apart  for  the  discussion  of  the  Dis- 
eases of  the  Organs  of  Respiration.    Dr.  Smith's  connection  with  the 


508 


Reviews. 


[April 


Victoria  Park  Hospital  for  Diseases  of  the  Chest  has  given  him  entire 
familiarity  with  these  maladies,  and  no  one  can  arise  from  the  perusal  of 
these  pages  without  a  firm  conviction  that  the  author  is  master  of  his  sub- 
ject. The  opening  chapter  is  devoted  to  the  consideration  of  preliminary 
matters.  The  best  methods  of  examining  the  chest  in  children,  the  differ- 
ences impressed  upon  the  physical  signs  and  constitutional  symptoms  by 
the  age  of  the  patient  and  the  significance  of  the  different  signs  are  clearly 
and  concisely  given. 

The  chapter  on  Atelectasis,  Congenital  and  Post-Natal,  is  very  com- 
plete, and  is,  in  fact,  one  of  the  best  presentations  of  the  subject  with  which 
we  are  familiar. 

We  turn  with  considerable  interest  to  the  chapter  on  Pleurisy  to  learn 
how  much  light  the  author  is  able  to  throw  upon  the  many  points  in  this 
disease  still  considered  debatable.  There  is  perhaps  no  other  serious  affec- 
tion of  early  life  more  often  overlooked  than  pleurisy  :  this  is  largely  due 
to  the  insidious  manner  in  which  it  is  often  developed  in  infants,  especially 
in  those  suffering  from  wasting  diseases.  "  In  these  cases  there  is  often 
no  fever,  or  only  a  trifling  rise  of  temperature  :  there  may  be  no  cough, 
and  attention  may  only  be  directed  to  the  chest  by  noticing  that  the  child 
is  breathing  quickly  and  has  less  appetite  than  usual  for  his  food."  The 
difficulty  of  distinguishing  between  serous  and  purulent  effusion,  without 
an  exploratory  puncture,  is  clearly  stated.  Neither  temperature,  nor  length 
of  illness,  nor  physical  signs  offer  positive  testimony  as  to  the  nature  of  the 
fluid.  The  author,  however,  is  accustomed  to  rely  with  a  good  deal  of 
confidence  upon  a  peculiar  straw-yellow  hue  of  the  face  as  indicating  the 
presence  of  pus  in  the  thoracic  cavity.  This  color  is  unlike  the  complexion 
of  any  other  disease,  and  is  seldom  observed  before  the  second  week  of  the 
illness.  When  the  effusion  is  so  large  as  seriously  to  hamper  the  circula- 
tion and  produce  a  cyanotic  tint  of  the  skin,  or  if  absorption  has  not  taken 
place  after  the  lapse  of  three  weeks,  though  no  urgent  symptoms  are  pres- 
ent, the  use  of  the  aspirator  is  advised.  Even  in  empyema,  it  is  best  in 
the  first  instance  to  employ  aspiration,  as  sometimes  after  the  chest-cavity 
has  been  evacuated  by  this  means  the  fluid  is  not  reproduced.  The  danger 
of  sudden  death  from  rapid  withdrawal  of  the  effusion  from  the  chest  is 
noticed.  This  accident  may  arise  from  syncope,  from  rapid  interference, 
with  the  function  of  the  healthy  lung  or  from  cerebral  embolism.  If  puru- 
lent fluid  is  reproduced  after  one  or  more  aspirations,  or  if  the  fluid  with- 
drawn is  fetid,  a  free  opening  in  the  chest-walls  and  the  introduction  of  a 
drainage-tube  are  advised. 

' '  After  the  tube  has  been  inserted  the  chest  should  be  bound  round  with  an 
antiseptic  binder,  and  the  pleural  cavity  may  be  left  to  drain  itself.  It  will  not 
be  necessary  to  wash  it  out  with  disinfecting  solutions  unless  signs  of  decomposi- 
tion have  been  noticed.  If,  however,  the  pus  which  flows  after  the  operation  is 
fetid,  injections  of  a  solution  of  iodine  may  be  employed,  diluting  one  drachm  of 
the  tincture  with  one  ounce  of  water ;  or  carbolic  acid  may  be  used  diluted  with 
thirty  times  its  bulk  of  water.  This  measure  will  not  be  required  when  the  pus 
continues  to  be  perfectly  sweet.  In  such  cases  the  introduction  of  antiseptic 
solutions  seems  to  keep  up  an  irritation  which  it  is  desirable  to  avoid.  Moreover, 
the  operation  is  usually  distressing  to  the  patient,  and  is  not  without  danger,  for 
syncope  and  other  alarming  symptoms  have  sometimes  been  seen  to  follow  the 
introduction  of  the  fluid." 

In  view  of  the  well-recognized  danger  of  poisoning  from  the  absorption 
of  carbolic  acid,  we  are  inclined  to  question  the  propriety  of  using  it  at  ail 
for  washing  out  the  pus  cavity  :  in  any  event,  it  should  be  more  largely 
diluted  than  is  recommended  in  the  above  quotation. 


1885.] 


Smith,  Diseases  of  Children. 


509 


The  diseases  of  the  digestive  organs  are  considered  at  length  in  Part  IX. 

Infantile  Atrophy,  or  the  slow  wasting  which  is  so  common  in  hand-fed 
babies,  first  receives  attention.  This  condition,  which,  under  the  name  of 
"  Marasmus,"  finds  a  large  place  in  all  mortuary  tables,  the  author  states, 
"  is  a  perfectly  curable  complaint,  and  may  be  arrested  at  almost  any  stage 
by  the  exercise  of  judgment  and  care  in  the  feeding  and  general  manage- 
ment of  the  infant." 

In  this  chapter,  as  in  fact  all  through  the  book,  great  stress  is  laid  upon 
the  proper  feeding  of  infants  :  "  But  whatever  may  be  the  nature  of  the 
malady,  and  however  elaborate  may  be  the  medication  required,  the  details 
of  nursing  should  always  take  precedence  of  drug-giving." 

Dr.  Smith  strongly  emphasizes  the  fact,  so  often  overlooked  in  practice, 
"  that  feeding  and  nourishing  are  not  quite  the  same  thing."  Fresh  cow's 
milk  is  considered  the  most  eligible  substitute  for  the  mother's  milk. 
Condensed  milk  is  "  usually  well  digested,  but  the  nourishment  it  supplies 
is  very  inefficient  for  a  growing  baby." 

Barley  water  is  the  author's  favorite  diluent  for  cow's  milk  and  rarely 
disagrees  with  the  youngest  infant.  In  those  cases  in  which  ordinary 
cow's  milk  is  digested  with  difficulty,  Dr.  Roberts's  method  of  pancreatizing 
the  milk  is  highly  approved.  As  peptonized  milk  is  steadily  growing  in 
professional  favor,  we  append  the  formula  here  given  : — 

"  To  a  pint  of  new  cow's  milk  is  added  half  a  pint  of  boiling  water,  two  tea- 
spoonfuls  of  Benger's  pancreatic  solution,  and  twenty  grains  of  bicarbonate  of 
soda  dissolved  in  a  little  water.  The  whole  is  stirred  up  in  a  jug,  which  is  after- 
wards covered,  and  then  placed  in  a  warm  situation  under  a  '  cosey.'  At  the  end 
of  an  hour,  the  contents  of  the  jug  are  emptied  into  a  sauce-pan,  and  the  mixture 
is  boiled  for  two  minutes  to  stop  further  action  of  the  pancreatine  upon  the  milk. 
The  food  is  then  ready  for  use.  It  may  be  sweetened  to  the  child's  taste  with 
sugar  of  milk." 

The  author  describes  three  forms  of  diarrhoea.  Simple  non-inflamma- 
tory diarrhoea  (mild  intestinal  catarrh),  acute  inflammatory  diarrhoea 
(severe  intestinal  catarrh,  or  entero-colitus),  and  choleraic  diarrhoea  (in- 
fantile cholera). 

Our  space  will  not  permit  of  a  detailed  analysis  of  these  interesting 
chapters,  but  we  may  say  in  passing,  that  they  are  exceedingly  clearly 
written,  and  will  prove  trustworthy  guides  in  the  diagnosis  and  manage- 
ment of  these  common  and  dangerous  maladies. 

The  volume  closes  with  several  chapters  on  those  diseases  of  the  skin 
most  commonly  met  with  in  young  children.  Although  we  have  had  occa- 
sion to  point  out  some  of  the  shortcomings,  and  to  dissent  from  some  of 
the  teachings  of  Dr.  Smith's  book,  we  wish  to  say  that,  in  our  opinion,  it 
is  one  of  the  best  treatises  now  before  the  profession.  Unquestionably  it 
is  the  ablest  "  British  "  work  on  the  diseases  of  children  with  which  we 
are  familiar  :  it  has,  however,  some  strong  American  rivals,  which  it  will 
not  speedily  supplant  in  professional  favor. 

For  a  first  edition,  the  work  is  very  free  from  typographical  errors, 
although  an  unusual  number  of  well-known  proper  names  are  incorrectly 
spelled.  However,  a  very  unfortunate  misprint  occurs  on  page  676,  where 
the  author,  in  discussing  the  treatment  of  intussusception,  advises  :  "  For 
a  child  of  twelve  months  old,  one-twentieth  of  a  grain  of  .  morphia  and  a 
sixth  of  a  grain  of  atropine  may  be  used  every  half-hour  until  some  sensible 
effect  is  produced  upon  the  symptoms."  He  who  blindly  follows  the  text 
will  doubtless  soon  enough  perceive  "some  sensible  effect."  •  TV.  J.  C. 
No.  CLXXVIIL— April,  1885.  33 


510 


Reviews. 


[April 


Art.  XXI  Eleventh  Annual  Report  of  the  State   Commissioner  of 

Lunacy  of  the  State  of  New  York,  for  the  year  1883.  By  Stephen 
Smith,  M.D.,  Commissioner  of  Lunacy.  8vo.  pp.  491.  New  York, 
1884. 

The  Legislature  of  New  York  created  a  Board  of  State  Commissioners 
of  Public  Charities  in  the  year  1867.  New  York  was  the  second  State, 
Massachusetts  having  been  the  first,  to  provide  for  the  supervision  and 
examination  of  all  charitable  and  correctional  institutions  receiving  State 
aid,  with  power  to  visit  and  report  upon  all  hospitals,  asylums,  and  other 
places  where  the  insane  were  confined.  In  the  year  1872  the  Board  being 
of  the  opinion  that  great  advantage  would  be  derived  from  the  experience 
and  counsels  of  a  medical  associate,  procured  legislation  conferring  upon 
them  power  to  appoint  an  additional  secretary,  to  whom  should  be 
referred  matters  relating  specially  to  the  interests  of  the  insane.  In  1874, 
the  separate  office  of  Commissioner  of  Lunacy  was  created,  with  defined 
and  independent  powers,  all  connection  with  the  State  Board  of  Charities 
dissolved,  and  for  eleven  years  the  incumbent  has  been  at  the  head  of 
this  department  of  the  State  administration.  The  several  reports  of  the 
Commissioner  have  had  a  limited  circulation,  and  are  only  to  be  found  in 
the  repositories  of  public  documents.  The  valuable  information  procured 
at  great  expenditure  of  time  and  money  has  been  practically  inaccessible 
to  the  medical  profession  and  the  public,  because  of  the  refusal  of  the 
Legislature  to  print  any  extra  copies.  This  is  to  be  regretted,  as  the 
profession  and  the  public  are  interested  in  obtaining  from  official  sources 
knowledge  of  the  actual  state  and  requirements  of  the  various  asylums 
for  the  insane,  and  their  internal  administration,  not  only  on  account  of 
the  apparent  increase  of  insanity,  and  the  large  sums  annually  required  to 
provide  accommodation  for  the  insane,  but  also  because  the  frequent  agi- 
tation of  what  are  called  "  lunacy  reform"  questions  has  tended  to  exer- 
cise a  disquieting  effect  upon  the  public  mind. 

The  lunacy  history  of  the  past  fifteen  years  has  been  characterized  by 
unusual  activity  in  the  erection  of  hospitals  for  the  insane,  by  suggestions 
and  actual  changes  in  the  plans  of  construction  of  a  radical  character, 
marked  improvement  in  their  internal  administration,  proper  as  well  as 
unreasonable  criticism  of  asylum  management,  investigations  prompted 
by  allegations  of  abuses,  improper  detention,  as  well  as  a  desire  to  amend 
the  laws  providing  for  the  commitment  of  the  insane,  and  to  improve  the 
official  inspection  and  supervision  of  the  asylums.  Legislatures  are 
usually  ready  to  give  ear  to  allegations  of  abuse  of  a  public  trust  without 
due  consideration  of  the  sources  from  which  they  spring,  yet  it  must  be 
stated  that  the  many  investigations  throughout  the  country  have  shown, 
aside  from  the  occasional  unpleasant  experiences  which  must  ever  attend 
the  care  of  the  insane,  a  remarkable  exemption  from  official  mismanage- 
ment. 

There  is  usually  some  outcome  from  a  legislative  inquiry,  and  the 
agitation  in  the  State  of  New  York  in  1874  led  to  a  revision  of  the 
lunacy  laws,  a  new  form  of  commitment,  and  the  creation  of  the  office  of 
Commissioner  of  Lunacy.  The  tendency  of  legislation  in  the  State  of 
New  York  has  been  toward  centralization  of  power  and  responsibility  in 
administration  of  public  affairs,  and,  as  the  public  works  and  the  prisons 
have  severally  been  placed  under  a  single  head,  so  the  supervision  of  the 


1885.]    Report  of  the  Commissioner  of  Lunacy  of  New  York. 


511 


State  lunacy  system  has  been  devolved  upon  one  person  styled  the  Com- 
missioner of  Lunacy.  There  is  a  grave  objection  to  a  commission 
composed  of  one  member.  While  the  reports  of  an  efficient  officer  may 
become  a  valuable  repository  of  expert  information,  there  can  be  no 
permanent  accumulation  of  experience  in  conducting  examinations,  as  a 
retiring  commissioner  will  carry  with  him  the  important  personal  knowl- 
edge he  may  have  acquired.  Such  a  loss  to  the  service  and  the  State 
could  not  occur  if  the  commission  were  composed  of  several  members 
with  a  continuous  succession.  The  term  of  service  of  the  Commissioner 
is  fixed  at  five  years.  Under  such  circumstances  in  any  department  of 
the  public  service,  it  may  frequently  happen  in  the  future  as  in  the  past, 
that  when  an  officer  might  be  expected  to  be  best  qualified  to  prosecute 
his  work  from  the  valuable  experience  acquired,  he  must  give  place  to  a 
new  incumbent,  who  in  turn  spends  the  term  of  his  official  period  in 
obtaining  but  a  superficial  knowledge  of  its  duties. 

The  report  before  us  was  made  by  Dr.  Stephen  Smith,  who,  in  1882, 
succeeded  Dr.  Ordronaux,  the  first  incumbent  of  the  office.  Dr.  Smith 
is  known  to  our  readers  as  one  of  the  valued  contributors  to  the  medical 
periodical  literature  of  this  country,  as  an  author,  teacher,  member  of  the 
National  Board  of  Health,  and  as  an  industrious,  honest,  and  patient 
student  of  any  work  he  may  undertake.  The  report  is  a  document  of 
491  pages,  and  bears  evidence  of  a  painstaking  effort  to  present  the 
actual  condition  and  administration  of  the  several  asylums,  public  and 
private,  county  poor-houses  and  asylums  where  the  insane  are  cared  for, 
as  they  appeared  to  him  on  actual  inspection,  clothed  as  he  was  with  the 
ample  power,  and  charged  with  the  responsible  duties,  of  a  public 
inquisitor.  He  has  not  deemed  it  necessary  again  to  repeat  the  histories 
of  the  asylums,  or  to  discuss  medical  theories  and  questions  pertaining  to 
insanity,  which  have  encumbered  so  many  reports  from  this  office.  The 
intelligent  and  candid  readers  may,  therefore,  in  view  of  the  allegations 
which  have  too  frequently  been  made  in  reference  to  asylum  adminis- 
tration, form  their  own  conclusions,  and  perceive  how  a  plain  statement 
of  facts  from  an  unbiased  and  unimpeachable  observer  furnishes  a 
refutation.  The  Commissioner  has  introduced  his  official  probe  in  every 
direction,  and  presents  the  minute  details  of  hospital  life  and  adminis- 
tration. The  report  is  to  be  commended  to  State  officers,  who  are  too  prone 
to  present  their  own  conclusions,  without  furnishing  the  data  which  led 
to  their  formation. 

Whether  it  was  wise  to  dissolve  the  relations  which  existed  between 
the  Board  of  State  Charities  and  the  Commissioner  of  Lunacy,  does  not 
appear  from  the  eleven  reports  thus  far  presented.  Both  departments 
have  co-ordinate  powers  in  the  visitation  of  public  institutions  where  the 
insane  are  cared  for,  yet  there  has  been  some  embarrassment  as  to  the 
limits  which  should  define  the  powers  of  each.  The  greatest  weight  will, 
however,  attach  to  the  observations  and  criticisms  of  a  trained  professional 
inspector  in  the  estimate  placed  upon  questions  strictly  medical. 

The  scope  of  the  Commissioner's  work  may  be  comprehended  from  the 
number  of  the  insane  in  the  State  and  in  institutions  Oct.  1st,  1883  : — 


512 


Reviews. 


[April 


In  State  hospitals  and  asylums,  eight  in  number      .        .       .  3,900 
City  asylums,  and  city  almshouses  ......  5,016 

County  asylums  and  county  poor-houses  .       .       .       .  .1,869 

Private  asylums      .......        .  558 

Aggregate  under  care     .       .       .       .       .       .       .  11,343 

The  number  in  family  care,  not  in  asylums  estimated       .       .  5,000 

Total  .16,843 

The  annual  increase  for  the  last  decade  has  averaged  500,  from  which 
it  may  be  estimated  that  in  1900  the  whole  number  will  exceed  20,000. 

The  total  amount  expended  in  plant  by  the  State  for 

the  care  of  the  insane  is   $5,865,327.70 

The  amount  expended  for  support  of  insane  in  the  State 

asylums  for  the  year  was         .....  $777,144.35 

The  contemplation  of  these  statistics  and  the  extraordinary  probabilities 
of  the  future  cannot  but  arrest  the  attention  of  the  profession,  which  must 
be  charged  with  devising  preventive  measures,  of  the  tax-payers  on  whom 
the  burden  of  support  must  rest,  and  of  those  who  may  feel  charged  with 
the  duty  of  directing  a  public  policy  toward  the  insane. 

The  insane  of  the  State  of  New  York  are  found  in  asylums  designated 
for  the  reception  of  recent  cases,  asylums  designated  for  the  chronic  insane, 
private  asylums,  city  asylums,  almshouses,  and  an  asylum  for  the  criminal 
and  convict  insane.  A  majority  of  the  trustees  of  one  of  the  asylums  must, 
by  law,  be  advocates  of  the  homoeopathic  system  of  medicine,  which  seems 
to  have  been  one  phase  of  an  attempt  to  establish  a  State  medicine.  There 
is  within  the  State  an  illustration  of  every  system  proposed  for  the  care 
of  the  insane.  It  is  not  a  matter  of  surprise,  therefore,  that  the  Commis- 
sioner remarks  that  "  No  one  can  examine  the  condition  of  the  insane, 
and  the  institutions  devoted  to  their  care  and  custody,  without  being  pain- 
fully impressed  with  the  entire  absence  of  any  well-organized  and  perma- 
nent system  of  management  of  this  unfortunate  class  in  the  State  of  New 
York.  They  are  found  in  every  conceivable  condition,  from  the  cheerful  and 
healthful  apartments  of  the  State  asylum  to  the  loathsome  and  pestilential 
cells  of  the  county  house.  Within  sight  of  each  other,  there  stand  to-day  in 
this  State,  institutions  devoted  to  the  care  of  the  insane  of  the  same  class,  in 
one  of  which  are  witnessed  the  vices  which  characterized  the  management 
of  similar  institutions  a  century  ago,  and  in  the  other  are  found  all  the 
ameliorating  conditions  of  the  highest  practical  philanthropy."  Incongru- 
ous as  the  whole  system  appears  to  be,  there  is  a  history  of  gradual  but 
decided  progress  beginning  with  the  enactment  of  a  law  in  1827,  prohib- 
iting the  care  of  lunatics  in  jails,  and  marked  successively  by  the  estab- 
lishment of  the  State  lunatic  asylums  for  the  indigent  insane,  and  others 
of  the  acute  class ;  the  creation  of  a  State  asylum  for  the  criminal  and 
convict  insane;  the  creation  of  the  Willard  Asylum  for  the  chronic  insane, 
with  a  mandatory  clause  requiring  the  insane  in  poor-houses  and  those 
discharged  from  the  hospitals  not  recovered  to  be  transferred  to  the  Wil- 
lard Asylum — thus  aiming  to  place  all  of  the  insane  under  State  care — the 
act  creating  a  State  Board  of  Charities,  with  powers  of  visitation,  and 
other  powers;  the  act  creating  a  Commissioner  of  Lunacy;  and,  lastly, 
the  application  of  civil  service  rules  to  the  appointments  in  asylums  for 
the  insane. 

It  would  appear  that  the  criticisms  apply  rather  to  the  insufficiency  of 
county  and  municipal  arrangements  for  the  care  of  the  insane.  The 


1885.]    Report  of  the  Commissioner  of  Lunacy  of  New  York. 


513 


incapacity  of  county  and  municipal  officers  is  proverbial.  They  are  given 
to  questions  of  taxation  and  politics,  and  sentiments  of  philanthropy  or 
the  medical  care  of  the  insane  have  no  abiding- place  with  them.  The 
history  of  county  care  of  the  insane  everywhere  is  that  of  scandalous 
neglect,  frequently  calling  for  the  interposition  of  the  sovereign  power  of 
the  State.  If  the  asylum  system  has  proved  inadequate,  the  Commissioner 
might  have  stated  that  the  new  hospitals  had  cost  so  much,  and  the  scale 
on  which  they  were  projected  was  of  such  a  magnitude  that  the  legisla- 
ture had  not  furnished  the  money  to  complete  the  buildings.  For  this 
result  those  who  have  approved  the  plans  were  in  part  responsible.  The 
cost  of  construction  and  subsequent  maintenance  has  had  the  effect  to 
cause  the  retention  in  their  homes,  and  in  poor-houses,  of  many  insane 
persons  who  otherwise  might  have  been  received  in  the  State  asylums. 

The  successive  steps  of  legislation  that  have  been  noticed  indicate  a 
considerable  advance  of  public  sentiment,  and  that  State  supervision  of 
the  insane  wherever  located  is  now  the  established  practice  and  policy  of 
the  State.  The  commissioner  is  not  vested  with  power  to  interfere  with 
or  direct  the  administration  of  the  asylums,  but  it  is  wisely  limited  to  the 
correction  of  evils  as  he  may  determine  that  they  exist,  and  for  this  pur- 
pose may  issue  an  order,  which,  if  resisted,  he  may  present  to  a  justice 
of  the  Supreme  Court,  who  may  take  proceedings  for  its  enforcement. 
The  Board  of  State  Charities,  also,  whenever  satisfied  that  the  provision 
for  the  insane  in  any  county  poor-house  is  inadequate  or  insufficient,  may 
direct  their  removal  in  ten  days.  Ample  power  is  thus  vested  in  state 
officers  to  correct  manifest  evils  and  abuses,  and  in  the  report  before  us 
we  observe  that  the  two  boards  have  cordially  co-operated  to  discharge  the 
responsibility  placed  upon  them.  The  commissioner  and  secretary  of  the 
Board  of  State  Charities  jointly  inspected  thirty  county  poor-houses,  and 
the  thirty  remaining  county-houses  were  visited  by  the  secretary  alone,  or 
in  company  with  a  commissioner  of  the  Board  of  State  Charities.  Com- 
paring the  condition  of  the  county-houses  as  described  in  the  Commissioner's 
report  with  inspections  made  by  Miss  Dix,  Dr.  Willard,  and  the  secretary 
in  1868,  it  is  evident  that  a  quiet  but  decided  transformation  has  taken  place 
in  the  direction  of  improvement.  The  discreet  manner  in  which  the 
visitations  were  made,  changes  suggested,  transfers  advised,  combined  with 
a  consciousness  that  the  state  officers  represented  the  sovereignty  as  well 
as  the  best  sentiment,  induced  a  prompt  co-operation  on  the  part  of  county 
officers.  Assurance  has  also  been  furnished  that  the  power  to  correct 
abuses  exists,  that  it  is  effectively  applied  when  required,  and  responsi- 
bility may  be  located  if  it  is  not  exercised. 

While  the  medical  profession  has  been  foremost  in  promoting  the  proper 
care  of  the  insane  wherever  found,  its  interest  centres  in  the  administra- 
tion of  the  State  hospitals  and  asylums.  It  is  a  subject  of  congratulation 
that  the  commissioner,  a  member  of  the  medical  profession  of  acknowledged 
standing  and  excellent  qualification,  with  no  asylum  proclivities  or  affilia- 
tions, has  presented  a  report  of  what  he  observed  and  ascertained  with 
painstaking  minuteness.  The  manner  and  extent  of  inspection  of  the 
State  asylums  were  as  follows:  The  records  were  examined  to  ascertain 
the  officers  on  duty  and  leaves  of  absence;  the  nature  of  the  medical 
service;  correctness  of  the  medical  certificates  ;  dates  and  completeness  of 
entries  in  the  case-books  ;  amount  and  kind  of  restraint ;  number  at  work 
and  kinds  of  employment ;  number  taking  narcotics  and  kind  of  drugs 
used  ;  number  filthy  and  requiring  night  attendance  ;  number  and  nature 


514 


Reviews. 


[April 


of  accidents  ;  number  of  visits  and  meetings  of  managers.  The  bed-rooms 
were  inspected  as  to  cleanliness,  amount,  kind,  and  condition  of  bedding; 
store-rooms  as  to  quality  of  stores,  methods  of  issue,  etc. ;  the  wards, 
dining-rooms,  tables,  and  kitchens  as  to  equipment ;  the  bath-rooms  and 
water-closets  as  to  their  sanitary  condition  and  water  supply;  patients  as 
to  their  bodily  cleanliness  and  existence  of  skin  diseases  ;  and  dining-rooms 
while  patients  were  at  meals.  The  steward's  books  were  examined  as  to 
the  methods  of  purchase  and  itemizing  accounts  and  also  the  system  of  audit- 
ing accounts  and  checks  by  which  irregularities  can  be  detected.  Night  in- 
spections were  made  to  determine  the  condition  of  patients.  Opportunities 
were  given  to  all  who  desired  private  conversation,  their  complaints  noted, 
and  inquiries  were  made  into  any  alleged  abuses.  .Although  "  the  Com- 
missioner is  empowered  to  enforce  certain  measures  by  means  of  an  order 
in  the  name  of  the  people  of  the  State,"  and  "  the  Commissioner  has 
studiously  investigated  every  case,  where,  from  complaint  or  evidence, 
there  was  reason  to  believe  that  it  might  be  necessary  to  exercise  these 
remedial  powers,  he  has  found  no  instance  where  such  relief  as  the  case 
demanded  was  not  found  to  be  obtainable  through  the  ordinary  channels." 
"The  evidence  that  any  person  was  wrongfully  deprived  of  his  liberty  by 
being  committed  to  and  confined  in  any  asylum  for  the  insane  in  this 
State,  has  not  proved  conclusive."  Dr.  Ordronaux,  for  eight  years  Com- 
missioner of  Lunacy  of  the  State  of  New  York,  made  a  statement,  that 
during  his  term  of  service,  though  his  office  was  open  daily,  no  complaint 
of  improper  detention  was  made  to  him,  and  he  had  not  discovered  a 
case  of  detention  for  improper  purposes.  These  statements  from  official 
sources  should  set  at  rest  the  ill-founded  suspicions  that  improper  and  illegal 
commitments  to  the  asylums  exist. 

For  several  years  a  degree  of  distrust  of  asylum  administration  has 
existed  in  the  public  mind,  promoted  somewhat  by  representations  ema- 
nating from  members  of^the  medical  profession,  which  the  Commissioner 
probably  had  in  mind  in  the  course  of  his  examinations.  It  has  been 
assumed  that  the  amount  of  mechanical  restraint  was  excessive ;  that 
where  mechanical  restraint  was  not  used,  narcotic  and  depressing  medi- 
cines were  substituted  ;  that  more  occupation  might  be  encouraged ;  that 
the  superintendent,  being  by  law  (which  he  had  no  part  in  framing)  re- 
sponsible for  the  proper  administration  of  every  department  of  the  asylum, 
could  not  render  his  patients  that  attention  they  required  ;  that  the  medical 
staff,  not  being  acquainted  with  advanced  doctrines  of  neurology,  therefore 
could  not  treat  insanity,  and,  as  a  consequence,  recoveries  had  diminished. 
The  criticisms  of  asylum  management  have  served  to  increase  the  popular 
distrust  which  so-called  "  asylum  outrages"  and  the  inevitable  unpleasant 
experiences  incident  to  the  care  of  the  insane  excite,  and  seem  to  have 
suggested  the  legislation,  founded  on  suspicion,  in  several  of  the  States. 
On  the  other  hand,  hospital  officers  have  undoubtedly  been  led  to  examine 
their  own  work,  to  institute  comparisons,  and  introduce  commendable 
improvements  in  their  practice. 

The  Commissioner's  report  shows  the  number  of  hours  mechanical 
restraint  was  applied,  and  the  kind  in  use,  from  which  we  infer  it  is 
fairly  reduced  to'a  minimum,  or  is  wholly  abolished.  The  best  attainable 
results  have  not  however  been  reached,  as  it  is  well  understood  that 
mechanical  restraint  may  be  dispensed  with  to  the  extent  that  a  higher 
standard  of  attendance  may  be  substituted  in  its  place.  The  abolition  or 
diminution  of  restraint  must  be  regarded  as  a  measure  of  the  quality  of 


1885.]    Report  of  the  Commissioner  of  Lunacy  of  New  York. 


515 


the  service  of  the  hospital.  While  the  use  of  restraint  may  not  be 
wholly  abolished,  the  day  has  probably  gone  by  when  its  use  will  be 
commended  and  defended  as  it  has  been  by  American  superintendents. 

The  report  of  the  use  of  narcotics  does  not  sustain  the  allegations  that 
their  use  is  excessive  or  suggest  a  suspicion  that  they  have  taken  the 
place  of  restraint.  On  the  contrary  the  quantity  is  surprisingly  small — 
less  than  the  best  practice  would  seem  to  sanction — one  asylum,  for 
instance,  reporting  but  three  doses  of  narcotic  medicine  administered 
during  the  year.  It  is  one  of  the  repeated  experiences  of  hospital 
practice  that  the  diminution  of  restraint  is  attended  with  a  greater  degree 
of  quietude  and  a  reduction  of  the  quantity  of  narcotic  medicines 
administered. 

As  diverse  opinions  exist  as  to  the  organization  of  hospitals  for  the 
insane,  we  quote  the  opinion  expressed  by  the  Commissioner : — 

"  A  critical  examination  of  the  organization  of  the  service  of  the  asylums  of 
this  State,  and  very  frequent  personal  inquiry  and  observation  as  to  the  practical 
daily  operations  of  such  service,  has  convinced  me  that  the  legislature  has  wisely 
laid  upon  the  superintendents  of  asylums  the  duties  of  executive  officers,  and 
clothed  them  with  such  large  powers,  to  be  exercised  under  the  jurisdiction  of 
boards  of  managers.  Abuses  may  occur  under  any  system  of  administration  of 
such  public  trusts,  where  large  numbers  of  officers  and  employes  are  essential  to 
the  proper  performance  of  the  routine  duties  involved,  but  it  is  certain  that  thus 
far,  during  forty  years  of  activity,  the  asylums  of  this  State  have  been  managed 
with  a  degree  of  success  and  popular  satisfaction  scarcely  attained  in  any  other 
branch  of  the  public  service.  Though  the  parent  institution,  the  State  Lunatic 
Asylum,  has  been  the  subject  of  frequent  and  severe  criticism,  and  the  most 
searching  and  exhaustive  official  examination  into  its  affairs,  yet  no  indictment 
has  been  found,  and  it  is  to-day  one  of  the  most  popular  asylums  in  this  country. 
Its  wards  are  always  filled  to  repletion,  and  no  asylum  can  show  so  large  a  per- 
centage of  recoveries."  "While  it  might  be  possible  to  attain  to  as  great 
efficiency  in  management  by  a  division  of  responsibility,  in  my  opinion  such  a 
result  would  be  a  rare  exception.  The  opportunities  for  peculation  are  many, 
and  when  once  the  supervision  of  the  single  responsible  head  is  withdrawn,  they 
might  be  abundantly  improved.  The  same  would  be  true  of  the  efficiency  in 
management,  when  the  machinery  was  disjointed,  and  each  part  was  run  in  its 
own  interest  by  independent  heads.  The  objection  to  the  law  making  the 
superintendent  the  sole  executive  officer,  based  upon  the  supposition  that  he  is 
thereby  prevented  from  giving  that  attention  to  patients  which  they  require,  is 
equally  fallacious.  It  is  true  that  a  superintendent  may  neglect  his  patients,  and 
devote  himself  entirely  to  the  business  affairs  of  the  asylum.  Neglect  of 
patients  would  probably  occur  with  such  a  superintendent  if  he  had  only  medical 
duties  to  perform.  It  is  certain  that  no  such  instance  of  incompetency  has  come 
within  my  knowledge  in  this  State." 

The  accumulation  of  chronic  cases  in  the  asylums  and  elsewhere,  the 
diminished  and  diminishing  number  of  recoveries,  is  one  of  the  most 
serious  subjects  to  contemplate  in  connection  with  the  report  before  us. 
It  foreshadows  the  increasing  burden  and  calamity  of  lunacy  to  individ- 
uals and  the  State.  The  increase  from  year  to  year  is  so  regular  as  to 
suggest  the  operation  of  uniformly  acting  causes.  The  Commissioner 
has  not  considered  the  causes  of  the  diminution  of  the  recoveries  as 
compared  with  those  of  former  years,  the  subject  of  preventive  measures, 
whether  the  hospitals  are  now  organized  in  the  best  manner  to  treat  the 
cases  that  are  susceptible  of  improvement,  nor  does  he  offer  any  criticisms 
or  suggestions.  Of  the  alleged  causes  of  insanity,  about  forty  per  cent, 
may  be  considered  avoidable  or  preventable,  inherent  to  the  social  organ- 
ization and  condition  which  we  call  our  civilization.    All'  these  relations 


516 


Reviews. 


[April 


deserve  the  more  careful  consideration  of  sociologists,  and  study  of  those 
engaged  in  the  moral  and  intellectual  training  of  the  young.  A  good 
work  is  yet  to  be  accomplished  in  this  field.  Notwithstanding  the  fact 
that  insanity  appears  to  be  increasing  in  the  State  of  New  York  in  a 
greater  ratio  than  the  population,  and  that  the  knowledge  and  study  of 
nervous  diseases  have  increased  during  the  last  decade,  the  percentage  of 
recoveries  reported  in  the  hospitals  has  been  lower  than  ever  before. 
While  formerly  the  duration  of  insanity  before  admission  to  the  hospitals 
was  less  than  six  months  in  the  majority  of  cases,  during  which  period 
the  probability  of  successful  treatment  is  greatest,  during  the  last  decade 
the  duration  of  insanity  in  the  largest  number  of  cases  was  more  than  six 
months  prior  to  admission.  The  inference  is  unavoidable  that  the  insane 
that  are  curable  have  been  retained  at  home,  or  elsewhere,  too  long,  from 
distrust  of  the  asylums,  or  for  treatment  outside  of  a  hospital.  Whether 
the  publicity  and  form  that  attend  commitments  to  the  hospitals,  which 
modern  legislators  have  deemed  it  wise  to  enact,  and  whether  physicians 
hesitate  to  take  the  responsibility  of  making  a  certificate  of  insanity 
until  active  symptoms  are  present,  have  served  to  retard  the  prompt 
treatment  of  the  insane,  are  fair  questions  to  be  considered  in  this  con- 
nection. From  whatever  cause  the  majority  of  the  insane  appear  to  have 
reached  the  hospitals  in  a  chronic  and  incurable  state.  Of  the  number 
of  curable  cases  treated  at  homes  and  in  private  families,  or  the  results 
of  such  treatment,  we  have  no  knowledge  as  no  reports  are  made, 
and,  therefore,  no  comparison  with  hospital  statistics  can  be  made.  In 
England  the  Lunacy  Commissioners  do  not  look  upon  the  isolated  care  and 
treatment  of  the  insane  with  favor.  We  would  regret  to  see  the  practice 
of  treating  single  patients  in  licensed  or  unlicensed  houses  introduced 
in  this  country,  unless  such  houses  were  under  the  management  of 
competent  medical  men. 

Our  space  does  not  permit  us  to  do  more  than  present  the  scope  and 
extent  of  the  Commissioner's  report,  which  is  a  monument  of  official 
industry,  fidelity,  and  hard  work.  It  is  apparent  from  a  perusal  of  the 
report  that  great  advances  have  been,  and  can  be,  made  in  the  internal 
administration  and  standard  of  care  of  the  asylums,  which  must  result  in 
the  restoration  of  confidence.  It  is  a  complete  official  refutation  of 
many  of  the  allegations  so  often  recklessly  made.  It  illustrates  the  good 
service  that  may  flow  from  co-operation  with  the  wise  counsels  of  a  state 
officer,  and  the  importance  of  a  state  system  of  inspection,  under  which 
the  best  methods  may  be  ascertained  and  applied.  J.  B.  C. 


Art.  XXII  A  Text-Book  of  Hygiene.    A  Comprehensive  Treatise 

on  the  Principles  and  Practice  of  Preventive  Medicine  from  an  Ameri- 
can Standpoint.  By  George  H.  Rohe,  M.D.,  Prof,  of  Hygiene,  Col- 
lege of  Physicians  and  Surgeons,  Baltimore  ;  Member  of  the  American 
Public  Health  Association  ;  of  the  Medical  and  Chirurgical  Faculty  of 
Maryland,  etc.  etc.    pp.  324.    Baltimore :  Thomas  &  Evans,  1885. 

The  elevated  standard  of  medical  education  demanded  by  the  Illinois 
State  Board  of  Health  in  regard  to  sanitary  science  has  not  only  resulted 
in  the  addition  of  chairs  of  hygiene  to  several  of  our  more  progressive 
colleges,  but  has  also  stimulated  the  production  of  suitable  text-books,  of 


1885.]      Reeves,  Bodily  Deformities  and  their  Treatment.  517 


which  this  one  is,  as  far  as  we  know,  the  first  purely  American  representa- 
tive. In  his  pithy  preface  Prof.  Rohe  informs  his  readers  that  the  aim 
has  been  to  place  in  the  hands  of  the  American  student,  practitioner,  and 
sanitary  officer  a  trustworthy  guide  to  the  principles  and  practice  of  pre- 
ventive medicine.  Also  that  he  has  sought  to  present  the  essential  facts 
upon  which  the  art  of  preserving  health  is  based,  in  clear  and  easily  un- 
derstood language.  Lastly,  that  whilst  he  cannot  flatter  himself  that  much 
in  the  volume  is  new,  he  hopes  nothing  in  it  is  untrue. 

The  book  opens  abruptly  without  explanation  or  introduction,  with  the 
chapter  on  air,  including  a  brief  exposition  of  the  composition  of  the  atmo- 
sphere, the  influence  of  changes  of  temperature  upon  health,  and  similar 
topics.  The  important  subjects  of  water,  food,  soil,  removal  of  sewage, 
construction  of  habitations,  hospitals,  and  schools  are  next  treated,  after 
which  succeed  chapters  on  industrial,  military,  marine,  and  prison  sanitation. 
A  short  section  comprising  personal  hygiene  is  followed  by  a  discussion  of 
the  germ  theory  of  disease,  the  history  and  prophylaxis  of  particular  con- 
tagious or  epidemic  diseases,  and  the  volume  concludes  with  a  consideration 
of  antiseptics  and  disinfectants,  quarantine  and  vital  statistics,  to  each  of 
which  a  few  pages  are  devoted. 

The  author  writes  in  a  pleasing  and  agreeable  style,  and  his  descriptions 
of  modes  of  investigation  in  the  earlier,  and  of  diseases  with  their  prophy- 
laxis in  the  latter  part,  are,  as  a  general  rule,  clear,  concise,  and  accurate. 
The  great  fault  of  the  work  is  that  of  omission,  and  although  no  doubt  this 
is  the  result  of  our  author's  praiseworthy  attempt  to  condense  the  essen- 
tials of  the  most  important  branch  of  all  human  knowledge  into  one  small 
treatise,  it  would  not  be  difficult  to  point  out  matters  of  vital  interest  to 
every  sanitarian,  which  should  have  been  discussed  in  its  pages.  Absence 
of  specific  details  in  regard  to  testing  for  adulterations  in  the  chief  articles 
of  food,  or  of  impurities  in  air  and  water,  is  much  to  be  regretted.  In  fact, 
Dr.  Rohe  seems  quite  ignorant  of  the  great  test  for  dangerous  organic  im- 
purity in  water,  which  we  possess  in  Nessler's  reagent,  a  test  of  such  delicacy 
and  value  that,  according  to  Wanklyn,  no  other  can  even  compare  with  it. 
The  scanty  reference  to  methods  of  microscopic  investigation,  and  the  total 
want  of  illustrative  figures,  also  constitute  serious  defects,  which  will  no 
doubt  be  remedied  in  future  editions  of  this  very  useful  work. 

An  admirable  feature  of  the  book,  and  one  which  goes  far  to  compensate 
for  the  evils  of  excessive  condensation,  is  the  excellent  list  of  references 
appended  to  each  chapter.  By  the  aid  of  these,  students  who  are  blessed 
with  ample  time  and  abundant  pecuniary  resources  can  fully  inform  them- 
selves upon  any  particular  question  relating  to  the  present  state  of  sani- 
tary science.  J.  G.  R. 


Art.  XXIII  Bodily  Deformities  and  their  Treatment,  a  Handbook  of 

Practical  Orthopcedics.  By  Henry  Albert  Reeves,  F.R.C.S.E., 
Surgeon  to  the  Royal  Orthopasdic  Hospital,  to  the  East  London  Chil- 
dren's Hospital,  and  to  the  Hospital  for  Women  ;  Senior  Assistant  Sur- 
geon and  Teacher  of  Practical  Surgery  at  the  London  Hospital.  Small 
8vo.,  450  pp.    Philadelphia:  P.  Blakiston,  Son  &  Co.,  1885. 

In  examining  a  work  of  this  kind,  it  is  but  justice  always  to  keep  prom- 
inently before  the  mind  the  exact  limitations  set  for  himself  by  the  author. 
This  will  appear  a  still  more  imperative  duty  when  wre  examine  in  detail 


518 


Reviews. 


[April 


the  extensive  range  of  subjects  embraced  within  the  small  compass  of  450 
pages,  a  distinct  proportion  of  which  are  also  occupied  by  the  228  illus- 
trations, thus  considerably  lessening  the  text. 

In  his  preface  the  author  states  that  he  has  approached  his  subject  from 
the  standpoint  of  the  general  surgeon.  Herein  both  reader  and  patient 
are  to  be  congratulated,  for  we  hold  that  he  only  should  be  a  specialist 
who,  first  having  had  a  considerable  experience  as  a  general  practitioner 
or  surgeon,  by  some  special  aptitude,  or  from  the  force  of  circumstances, 
gravitates,  as  it  were?  into  some  special  line  of  practice.  Recognizing  the 
patent  fact  that  no  one  comprehensive  work  on  Orthopaedics,  in  its  modern 
sense,  has  been  as  yet  written,  although  many  good  works  are  extant  treat- 
ing of  the  various  sections  of  this  branch  of  surgery,  Mr.  Reeves  has 
attempted  to  fill  this  acknowledged  want  by  a  comprehensive,  concise,  and 
cheap  practical  work,  founded  on  "a  large  special  and  general  experience," 
and,  considering  the  almost  insuperable  difficulties  of  such  a  task,  we  must 
confess  that  he  has  acquitted  himself  admirably. 

Although  there  are  of  necessity  omissions,  faults,  and  errors,  we  consider 
the  book  a  good  one,  and  chiefly  because,  while  sufficiently  magisterial,  it 
is  an  eminently  suggestive  work,  in  that,  while  distinctly  advocating  the 
author's  special  views,  it  gives  in  a  succinct  way  such  hints  and  actual 
statements  of  the  views  of  other  authorities,  that  the  reader  is  at  once  put 
in  the  possession  of  an  excellent  general  idea  of  the  subject,  and  sufficient 
data  to  enable  him  readily  to  push  his  researches  further,  should  he  see  fit. 

When  we  mention  the  various  subjects  treated  of  in  this  book,  it  will 
at  once  become  manifest  that  we  cannot  notice  each  in  detail.  We  shall, 
therefore,  confine  our  remarks  to  those  points  which  seem  to  us  specially 
deserving  of  praise  or  blame.  The  work  opens  with  a  brief  chapter  on 
orthopaedics  in  general,  which  judiciously  omits  anything  like  a  history  of 
the  art,  but  gives  appropriate  references  to  the  sources  wherein  such  infor- 
mation should  be  sought.  This  chapter  includes  a  general  consideration 
of  the  causation  of  deformities,  their  prophylaxis,  and  the  general  principles 
governing  their  treatment. 

Rickets  surgically  considered  is  sufficiently  well  treated  of,  except  that 
we  must  protest  against  such  an  exceedingly  crude  pathological  descrip- 
tion of  its  first  stage  as  the  statement,  that  the  bones  "are  infiltrated  with 
a  blackish,  bloody  matter."  Such  a  description  is  certainly  no  aid  to  an 
understanding  of  the  method  of  invasion,  the  cause  of  the  deformities  in, 
and  the  means  best  calculated  to  relieve  and  cure  this  disease — rather, 
indeed,  the  reverse. 

A  noticeable  and  commendable  feature  of  this  work  is  that  the  French, 
German,  Latin,  Greek,  and  English  synonyms  of  the  various  affections 
are  given  immediately  after  the  definition  of  each  disease.  A  congenital 
and  acquired  form  of  scoliosis  is  recognized,  the  latter  being  due  to  idio- 
pathic, traumatic,  rachitic,  inflammatory,  or  statical  causes.  The  note- 
worthy points  as  to  the  author's  views  of  the  pathology  of  this  affection  are 
that  he  believes  that  some  few  cases  "  can  only  be  satisfactorily  explained 
by  altered  growth  or  ossification  in  the  affected  portion  of  the  spine,"  and 
"  that  in  many  cases  the  causes  are  manifold  rather  than  single  and  sim- 
ple." Careful  perusal  of  the  text  gives  us  the  impression  that  the  author 
has  no  very  definite  belief  as  to  the  causation  in  many  cases,  with  the  ex- 
ception of  those  mentioned,  and  that  "  vertebral  articular  disease"  is  an 
occasional  cause.  His  remarks  on  the  diagnosis  of  scoliosis  are  judicious 
and  trustworthy,  but  we  cannot  agree  with  him  that  any  degree  of  "  double 


1885.]      Reeves,  Bodily  Deformities  and  their  Treatment.  519 


curvature"  of  the  spine  can  exist  to  which  the  surgeon's  attention  would 
be  called,  without  torsion  of  the  spine,  as  he  seems  to  suggest  does  occur. 
Our  reasons  are  anatomical  and  mechanical,  but  cannot  be  entered  into 
here.  It  is  possible  that  Mr.  Reeves  means  that  this  torsion  cannot  readily 
be  made  out  in  certain  cases,  in  which  opinion  we  concur.  Under  treat- 
ment, active  and  passive  gymnastics,  especially  swimming  either  "  wet  or 
dry,"  auto-suspension,  etc.,  are  judiciously  described  and  advocated  for 
selected  cases.  Mr.  Reeves  thinks  it  is  "  a  pity"  that  we  seem  to  have 
entirely  given  up  the  use  of  orthopasdic  beds.  Lund's  recent  couch,  lateral 
decubitus  by  the  aid  of  pillows,  or,  still  better,  by  Wolff's  suspensory  cra- 
dle, are  strongly  recommended,  and,  we  think,  deserve  commendation. 
As  to  spinal  supports  and  corsets,  he  is  an  utter  disbeliever  in  the  efficacy 
of  the  elastic  traction  of  Barwell,  and  condemns  the  plaster  jacket  as 
ordinarily  applied,  but  believes  that  in  hospital  practice,  where  expense  is 
an  object,  the  following  modification  of  Sayre's  apparatus  is  serviceable  in 
certain  cases  of  incipient  lateral  spinal  curvature.  Thick  pads  are  placed 
in  the  concavity  of  the  curve  before  the  jacket  is  applied.  When  set,  cor- 
responding holes  are  cut  out  of  the  jacket  and  the  pads  removed,  thus 
"leaving  room  for  expansion  of  the  chest  and  of  the  concavity  of  the 
curve." 

Although  Mr.  Reeves  has  devised  a  modification  of  the  ordinary  spinal 
support  which  is,  in  his  opinion,  a  "  perfection,  though  not,  perhaps,  a 
perfect  instrument,"  we  shall  quote  the  following  emphatic  sentences  as 
the  best  expression  of  his  opinion  concerning  spinal  apparatus  :  "  I  wish 
it  to  be  clearly  understood  that  I  look  upon  spinal  instruments  only  as 
valuable  adjuncts  ;  if  they  be  trusted  to  alone,  disappointment  will  be  the 
result."  Would  that  all  other  orthopaedists  were  as  moderate  in  pressing 
the  claims  of  their  own  methods,  and  were  as  truly  scientific  in  their  views 
of  treatment ! 

Forcible  rectification  of  the  spine,  the  author  thinks,  may  prove  useful 
in  a  very  few  selected  cases,  and  he  proposes  to  try  it.  We  think  that  he 
had  better  not.  Deformities  of  the  chest  and  abdomen  are  next  briefly 
considered.  Wry-neck  is  described  as  being  permanent,  intermittent, 
spasmodic,  symptomatic  or  essential,  osseous,  and  articular.  Judicious 
advice  is  given  as  to  treatment  of  each  variety.  The  author's  experience 
of  five  cases  of  stretching,  or  excision  of  the  spinal  accessory  nerve  before 
or  after  tenotomy,  leads  him  to  view  the  operation  unfavorably.  The  chap- 
ters on  cyphosis  and  lordosis  present  no  points  of  special  interest. 

The  section  on  spinal  caries  is  an  excellent  one,  wherein  the  writer 
says,  "  I  freely  admit  that  injury  may  frequently  be  the  actually  known  or 
the  unrecognized  cause  of  the  disease,"  but  "I  cannot  admit  it  as  the  only 
cause,  and  to  the  exclusion  of  others  due  to  local  and  constitutional  states." 
He  admits  that  when  force  is  "  transmitted  through  the  ribs  to  the  verte- 
bral articular  facets,"  it  is  "  probable  that  an  arthritis  is  set  up  which  may 
spread  through  the  processes  to  the  vertebral  bodies,  and  thus  cause  the 
disease.  Of  this  I  am  sure,  that  in  considering  cases  of  spinal  caries,  we  too 
often  overlook  the  undoubted  fact  that  disease  of  the  vertebral  joints  may 

coexist,  or  even  be  independently  present  Tubercle  and  syphilis 

are  not  infrequent  causes  of  the  disease ;  and  osteitis  with  cheesy  degene- 
ration may  follow  the  continued  fevers,  or  be  due  to  the  vital  depression 
from  some  long  or  serious  illness."  It  will  be  gathered  from  these  quota- 
tions that  this  judicious  author  is  no  extremist,  neither  a  traumatist  nor  a 
constitutionalist,  if  we  may  so  term  it ;  but  a  truly  broad-minded  clinical 


520 


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[April 


observer,  one  who  allows  no  preconceived  opinion  to  stultify  the  teachings 
of  his  own  experience.  In  addition,  Mr.  Reeves  believes  that  the  caries 
may  commence  peripherally,  i.  <?.,  as  a  periostitis,  or  centrally,  i.  e.,  as  an 
ostitis  of  the  vertebral  body.  Caries  sicca  is  recognized,  and  considered 
to  be  due  most  commonly  to  gout  or  rheumatism.  Primary  disease  of  the 
intervertebral  fibro-cartilages  is  thought  to  be  very  rare. 

A  case  quoted  from  Gibney  will  afford  comfort  to  some  of  the  unfortunate 
general  practitioners  who  are  sometimes  unjustly  blamed  by  specialists  for 
not  detecting  spinal  caries  in  its  earliest  stages.  On  this  patient  five  diame- 
trically opposed  diagnoses  were  made,  and  when  reported  the  sixth  could 
not  be  made,  as  no  opinion  could  be  arrived  at !  'We  do  not  quote  this  to 
encourage  carelessness,  but  to  afford  comfort  to  those  finding  it  difficult  to 
arrive  at  a  correct  conclusion  in  doubtful  cases.  In  the  treatment,  Rauch- 
fuss's  spinal  cradle  is  recommended  for  certain  cases.  Rest  in  bed  with  a 
moulded  leather,  felt,  or  gutta-percha  back-splint  should  be  persevered  in, 
either  continuously  or  for  a  certain  portion  of  the  day,  until  anchylosis  is 
far  enough  advanced  to  allow  of  locomotion  alternating  with  recumbency, 
when  a  spinal  support  should  be  worn. 

Mr.  Reeves  considers  Sayre's  jacket  dangerous  when  the  disease  is 
active,  or  when  there  is  much  destruction  of  bone. 

"In  hospital  practice,"  however,  "  where  time  and  expense  are  objects,  and 
in  cases  in  which  anchylosis  is  proceeding  favorably,  I  think  a  jacket  a  cheap  and 
efficient  support,  if  properly  applied ;  but  I  would  do  away  with  extension  alto- 
gether in  spinal  caries,  because  it  is  mischievous  in  the  active,  acute,  and  destruc- 
tive stages,  and  when  anchylosis  is  proceeding  it  is  not  necessary,  and  may  be 
harmful." 

We  heartily  indorse  the  above,  having  entirely  abandoned  suspension, 
resorting  instead  to  the  hammock  when  applying  a  jacket. 

Posterior  incision  of  spinal  abscesses  with  the  removal  of  carious  or  ne- 
crotic bone  is  mentioned  with  a  qualified  commendation,  the  procedure 
being  still  on  trial  and  sometimes  impossible  to  complete  even  by  those 
somewhat  experienced  in  this  operation. 

As  was  to  be  expected,  much  space  is  devoted  to  the  discussion  of  talipes 
in  all  its  forms.  Some  interesting  statistics,  drawn  from  many  sources, 
are  given  of  the  actual  frequency  of  club-foot  among  the  new-born,  and 
the  relative  frequency  of  the  different  varieties.  Mr.  Reeves's  personal 
experience  of  the  congenital  forms  convinces  him  that  equino-varus  occu- 
pies the  first  rank,  then  equino-valgus,  next  valgus  and  equinus,  and  last 
calcaneus.  The  etiology  of  both  the  congenital  and  acquired  forms  is  most 
thoroughly  but  concisely  discussed,  and  the  conclusions  at  which  the  author 
has  arrived  can  best  be  given  in  his  own  words : — 

"  At  present  the  etiology  of  the  subject  is  obscure,  and  the  most  that  can  be 
said  is  that  the  mechanical  or  malposition  theory  appears  to  be  the  more  proba- 
ble. I  am  inclined  to  think  that  the  causes  of  club-feet  are  not  single  and  inva- 
riable, and  there  can  be  little  doubt  that  acquired  club-foot,  and  such  as  those  of 
which  all  experienced  men  must  have  had  the  opportunity  of  watching  the  devel- 
opment, are  undoubtedly  due  to  affections  of  the  nerves,  muscles,  fascia,  etc.,  so 
that,  for  my  own  part,  I  see  no  difficulty  in  believing  that  if  the  nervous  system 
were  disturbed  during  intra-uterine  life,  and  affected  the  muscles  acting  upon  the 
foot,  these  might  readily  induce  alterations  of  the  cartilaginous  predecessors  of  the 
tarsal  bones  in  the  congenital  forms." 

Although  the  descriptions  of  the  different  forms  of  club-foot  are  good, 
and  the  directions  as  to  treatment  are,  in  the  main,  most  judicious,  we 


1885.J      Reeves,  Bodily  Deformities  and  their  Treatment. 


521 


shall  only  touch  upon  a  few  points  here  and  there.  Mr.  Reeves  inculcates 
the  necessity  of  the  "  more  gradual  extension  than  in  ordinary  cases"  for 
paralytic  club  feet  when  tenotomy  becomes  necessary,  because  massage, 
electricity,  and  proper  apparatus  do  not  improve  them,  lest  the  opposite 
deformity  be  induced. 

Except  in  the  slightest  cases,  Mr.  Reeves  thinks  that  tenotomy  is  abso- 
lutely necessary  and  other  measures  are  a  mere  waste  of  time,  although 
invaluable  after  tenotomy.  In  relapsed  cases  after  tenotomy,  when  this  ope- 
ration is  again  performed,  the  blunt  tenotome  should  be  used  in  various 
directions,  "especially  up-  and  downwards"  to  separate  the  adhesions. 

The  author's  modification  of  Scarpa's  shoe  is  recommended,  also  Mr. 
Baker's  apparatus.  Although  clumsy  to  an  American  eye,  they  are  pro- 
bably quite  as  effective  as  our  more  delicate  pieces  of  mechanism.  "We 
are  particularly  pleased  at  Mr.  Reeves's  scientific  fairness,  which  induces 
him  to  point  out  the  indications  for  treatment,  and  while  naturally  pre- 
ferring his  own  methods  of  carrying  these  out,  still  candidly  admits  that 
there  are  other  plans  which  may  also  be  equally  efficacious.  Tarsotomy  in 
all  its  modifications  is  looked  upon  with  no  special  favor,  and  should  be 
restricted  chiefly,  if  not  entirely,  "  to  neglected  or  badly  relapsed  cases  of 
adolescents  and  adults."  Even  for  such  cases  "  the  immediate  rectifica- 
tion" "  by  multiple  tenotomy  or  by  open  division"  under  anaesthesia  is 
preferred,  followed  by  fixation  with  a  plaster  bandage.  Our  personal  ex- 
perience certainly  bears  out  the  author  in  all  except  the  "open  division," 
of  which  we  have  had  no  experience,  but  which  we  shall  certainly  re- 
sort to  before  trying  any  form  of  tarsotomy.  As  Mr.  Erichsen  has  said, 
many  of  these  modern  operations  are  at  their  best  "  surgical  audacities," 
while  some  are,  in  the  words  of  Mr.  Jackson,  of  Sheffield,  "surgical 
atrocities." 

Many  pages  might  be  written  containing  much  of  interest  concerning 
the  author's  able  exposition  of  the  many  varieties  of  club-feet  met  with 
in  practice,  but  we  leave  the  reader  to  obtain  this  information  from  the 
original. 

From  the  author's  immense  personal  experience  in  osteotomy,  the  chapter 
on  this  subject  is  of  especial  interest,  he  having  performed  over  five  hun- 
dred operations  of  this  nature.  For  reasons  too  many  for  recital,  the 
author  prefers  diaphysial  osteotomy  of  the  femur  for  genu  valgum  to  any 
of  the  other  methods  in  vogue,  having  substituted  it  for  his  own  "  linear 
incomplete  condylotomy."  This  latter  operation,  he  maintains,  does  not 
result  in  the  opening  of  the  joint,  although  theoretically  it  ought  to  do  so, 
and  that  the  temporary  joint  effusion,  which  sometimes  occurs,  is  rather 
the  result  of  the  force  used  in  straightening  the  limb  than  due  to  opening 
of  the  articulation.  Three  points  are  especially  to  be  noted  with  reference 
to  incomplete  condylar  osteotomy:  (1)  to  leave  the  wound  alone  unless 
there  are  some  distinct  indications  for  interference ;  (2)  to  commence 
passive  motion  early  ;  and  (3)  not  to  over-correct  the  deformity,  as  is  some- 
times done. 

Delore's  method  of  "  forcible  manual  reduction"  meets  with  guarded 
approval  for  certain  cases  under  twelve  years  of  age  and  before  the  period 
of  sclerosis  in  rachitic  cases,  but  the  disadvantages  are  the  possibility  of 
a  weak  and  lax  joint,  and  the  frequent  necessity  of  a  retentive  apparatus 
to  permit  of  safe  progression  and  also  to  prevent  relapse.  McEwen's 
supra-condylar  incomplete  osteotomy  with  chisels  which  constantly  de- 
crease in  size  is  disapproved  of,  as  such  frequent  introduction  of  instru- 
ments is  apt  to  bruise  the  soft  parts  and  so  favor  suppuration.  The 


522 


Reviews. 


[April 


author  figures  a  graduated  chisel  or  osteotome  which  enables  the  operator 
to  judge  of  the  depth  to  which  it  has  penetrated  the  bone.  This  instru- 
ment was  suggested  by  Mr.  Parker,  a  colleague  of  Mr.  Reeves  at  the 
East  London  Children's  Hospital.  The  author  also  objects  to  Esmarch's 
bandage  and  antiseptic  precautions  during  the  performance  of  any  kind  of 
osteotomy.  Mr.  Reeves  disapproves  of  Ollier's  epiphysial  chondrotomy, 
but  thinks  that  possibly  osteoclasy  with  improved  instruments  may  "  be 
permanently  revived  and  practised." 

Congenital  displacements  of  the  hip  and  lower  limb  are  quite  exhaust- 
ively considered.  The  pathogenesis  of  the  former  is  considered  to  be 
different  in  different  cases,  both  defective  development — the  commonest 
cause— and  mechanical  force  in  delivery  being  recognized  as  standing  in 
a  causative  relation  to  this  malformation.  The  chapter  on  deformities  of 
the  toes  we  think  very  defective  in  that  their  pathogenesis  is  either  care- 
lessly or  ignorantly  taught.  The  varieties  are  numerous,  and  the  practical 
remarks,  although  perhaps  lacking  in  clearness  from  their  excessive  con- 
ciseness, are  fairly  good. 

Deformities  of  the  upper  limb,  both  congenital  and  acquired,  form  an 
interesting  chapter.  Dupuytren's  contraction  is  thoroughly  considered. 
The  author  states  that  not  only  the  fascia  but  the  skin  and  subcutaneous 
tissue  are  "  considerably  affected  ;  whether  secondarily  or  primarily,"  he 
does  not  decide.  After  giving  a  resume  of  the  opinions  and  experience  of 
other  surgeons — even  quoting  the  histories  of  special  cases — he  concludes : 

"that  one  should  first  try  the  subcutaneous  plan,  and  if,  in  severe  eases,  this 
should  fail  after  a  fair  trial,  then  one  of  the  methods  by  open  wound  may  be 
adopted,  and  if  care  be  taken  not  to  interfere  with  the  tendinous  sheaths,  and  to 
avoid  injury  to  vessels  and  nerves,  excellent  results  may  thus  be  obtained." 

The  pathology  and  pathogenesis  of  "jerk,  snap,  or  spring  finger"  are 
elaborately  considered,  but  anything  further  about  this  rare  affection  must 
be  here  omitted  lest  this  review  exceed  legitimate  limits. 

Anchylosis  and  unreduced  luxations ;  nervous  deformities  and  muscular 
contractions,  including  infantile  spinal  paralysis  and  its  consequences ;  de- 
formities of  the  nose  and  ear ;  osteotomy  for  irremediable  equinus ;  and 
trephining  for  Pott's  disease  close  the  very  imperfect  list  of  subjects  which 
we  have  found  space  to  notice,  many  subjects  having  been  not  even  men- 
tioned by  name. 

From  what  we  have  already  said  it  will  be  seen  that  Mr.  Reeves  has, 
in  a  compact  form,  given  us  a  trustworthy  guide  for  the  treatment  of  a 
very  extended  class  of  cases.  We  look  upon  the  book  as  a  valuable  com- 
pend  of  orthopaedics,  although  there  are  many  minor  points  'in  which 
we  markedly  differ  from  the  author.  The  cuts  are,  as  a  rule,  miserable 
from  the  artistic  standpoint,  but  we  must  confess  they  show  clearly  the 
points  that  they  are  intended  to  illustrate,  which  is  more  than  many  artistic 
drawings  do.  If  the  other  volumes  of  the  "Practical  Series"  are  as  good 
as  this,  we  shall  be  agreeably  disappointed  ;  and  we  may  be  permitted  to 
hope  that  their  illustrations  will  be  made  artistic  as  well  as  clear. 

C.  B.  N. 


1885.] 


Health  Reports. 


523 


Art.  XXIV  Health  Reports. 

1.  Fourth  Annual  Report  of  the  State  Board  of  Health  of  New  York. 

Transmitted  to  the  Governor  Feb.  21,  1884.  Pamphlet,  pp.  442. 
Albany,  1884. 

2.  Eighth  Annual  Report  of  the  Board  of  Health  of  the  State  of  New 

Jersey,  1884,  and  Report  of  the  Bureau  of  Vital  Statistics. 
Pamphlet,  pp.  375.    Trenton,  1884. 

1.  The  New  York  Report  opens  with  an  apology  for  imperfections  on 
account  of  the  sudden  death  of  the  lamented  Dr.  Elisha  Harris,  Secretary 
and  chief  executive  officer,  in  the  midst  of  his  usefulness,  and  before  its 
completion.  A  satisfactory  immunity  from  the  more  important  epidemic 
diseases  and  material  improvement  over  last  year,  in  regard  to  all  the 
preventable  maladies,  is  noted,  and  attributed,  no  doubt  correctly,  to  the 
systematic  sanitary  work  accomplished  by  the  State  and  local  Boards  of 
Health.  The  returns  of  vital  statistics,  however,  although  valuable,  are 
admitted  to  be  in  need  of  more  care  to  insure  complete  accuracy. 

In  regard  to  particular  diseases  diphtheria,  whilst  not  developing  as  a 
widespread  epidemic,  has  in  several  localities  broken  out  suddenly,  and 
been  for  a  time  quite  prevalent.  The  mortality  from  it,  proportionately 
very  severe  in  some  instances,  has  throughout  the  State  been  small  as 
compared  with  former  periods.  In  several  notable  cases  the  means  em- 
ployed to  prevent  a  further  extension  of  this  dreaded  complaint  were  emi- 
nently successful.  So,  too,  with  scarlet  fever ;  the  speedy  and  strict 
seclusion  from  schools  of  all  persons  connected  with  families  in  which 
cases  occurred,  the  quarantining  of  the  sick,  together  with  the  disinfection 
or  destruction  of  whatever  had  come  in  contact  with  them,  and  the  early 
and  private  burial  of  those  who  fell  victims  to  the  disease,  have^  been 
attended  with  highly  gratifying  results.  Measles  has  in  some  outbreaks 
been  of  exceptional  severity,  and  formed  the  subject  of  special  study. 
Typhoid  fever  has  been  the  most  prevalent  of  all  the  infectious  diseases 
coming  under  the  supervision  of  the  Board,  and  yet  in  but  few  places  has 
it  existed  as  a  considerable  epidemic.  The  success  of  the  Health  autho- 
rities in  stamping  out  what  threatened  to  become  a  widespread  epidemic 
of  smallpox  is  worthy  of  particular  notice.  It  originated  entirely  from 
one  case  of  the  malady,  the  subject  being  a  passenger  on  the  Lake  Erie 
and  Western  Railroad.  He  was  removed  from  the  train,  the  car  disin- 
fected, and  the  occupants  vaccinated.  The  disease  was  carried  to  the  town 
of  Hector  and  its  vicinity,  through  the  medium  of  an  occupant  of  the  in- 
fected car,  a  lady  of  very  advanced  age,  who  was  taken  sick  with  modified 
variola  at  the  residence  of  her  son,  with  whom  she  was  visiting,  and  to 
whom  she  communicated  the  disease.  She  had  been  allowed  to  go  from 
the  contaminated  car  unvaccinated,  for  the  reason  that  she  had  suffered  in 
early  life  from  smallpox,  a  circumstance  which  forcibly  illustrates  the  need 
there  is  for  the  utmost  thoroughness  in  vaccination  and  re-vaccination.  By 
the  prompt  action  of  local  boards  of  health,  a  number  of  which  were  stimu- 
lated into  organization  in  adjacent  towns  by  the  threatened  danger,  this 
epidemic,  which  gave  promise  of  wide  distribution  in  consequence  of  the 
large  number  of  people  exposed  before  the  disease  was  fairly  organized, 
was  cut  short.  Such  fortunate  abbreviation  was  accomplished  by  taking 
active  measures  to  quarantine  infected  districts,  and  to  protect  a  large 
number  of  the  neighboring  inhabitants  by  vaccinations.    As  a  gratifying 


524 


Reviews. 


[April 


result  of  the  vigilance  of  the  State  Board  of  Health  in  this  and  a  few 
other  instances,  New  York  State  has  been  unusually  free  from  smallpox 
during  the  year. 

An  excellent  illustration  of  the  immense  benefit  derivable  from  sanitary 
investigations  by  local  authorities  may  be  found  in  the  elaborate  report  on 
the  Topography,  Hydrography,  and  Drainage  of  Oak  Orchard  Swamp 
and  Basin  made  by  a  committee,  of  which  James  T.  Gardiner,  Director  of 
the  New  York  State  Survey,  was  chairman.  Among  the  examinations 
into  the  causes  of  prevalent  diseases  in  the  State  may  be  specially  mentioned 
first,  that  made  concerning  the  Sudden  Outbreak  of  Diphtheria  at  the  Ba- 
tavia  Blind  Asylum,  by  Richard  M.  Moore,  of  Rochester,  Sanitary  Inves- 
tigator for  the  west  district,  in  which  the  probable  origin  was  traced  to  sewer- 
gas  from  an  untrapped  bath-tub  near  the  bed  of  the  boy  first  attacked.  A 
second  valuable  report  in  this  series  is  the  one  made  by  Dr.  F.  C.  Curtis 
on  a  Sudden  Outbreak  of  Enteric  Fever  at  Port  Jervis  during  the  Fall  of 
1883,  in  which  a  very  careful  and  searching  examination  (a  model  for 
similar  investigations),  showed  that  the  cause  of  the  epidemic  was  infected 
milk,  which  was  known  to  be  supplied  to  eighty-seven  per  cent,  of  all  the 
patients  attacked.  A  very  interesting  article  on  Milk  Fresh  and  Con- 
densed, contributed  by  C.  E.  Munsell,  Ph.B.,  one  of  the  State  Inspectors 
of  milk,  contains,  among  other  evidences  of  faithful  attention  to  the  duties 
of  the  office,  the  gratifying  statement  that  at  the  present  time  only  about 
one  can  of  milk  in  forty  comes  to  the  city  watered,  whereas  a  few  years  ago 
nearly  one-fourth  of  the  500,000  quarts  of  alleged  milk  consumed  in  New 
York  City  was  water.  Mr.  Munsell  declares  analyses  are  not  generally 
made,  as  the  lactometer  is  positive  evidence  of  adulteration  by  water  if 
nothing  else  is  added,  or  if  the  cream  has  not  been  removed.  He  also  asserts 
that  the  minimum  total-solids  standard  of  11.5  per  cent.,  adopted  by  the 
British  Society  of  Public  Analysts,  is  too  low,  as  it  allows  the  removal  of 
one-third  the  cream  from  average  milk,  as  well  as  the  use  of  refuse  or  putrid 
feed  for  the  cows,  since  nothing  besides  distillery  swill  has  been  found  to 
produce  milk  below  that  quality.  After  some  valuable  reports  respecting 
the  action  of  the  Board  in  relation  to  sundry  nuisances,  especially  that 
created  by  the  Glen  Cove  Starch  Manufacturing  Company,  the  volume 
concludes  with  an  interesting  article  by  Edward  W.  Martin,  Milk  Inspec- 
tor, on  Milk  and  its  Adulterations,  which  is  illustrated  by  some  reproduc- 
tions of  excellent  micro-photographs,  representing  the  lacteal  fluid  in 
healthy  and  diseased  conditions. 

2.  The  New  Jersey  Report  also  expresses  gratification  that  the  year  1884 
has  been  one  of  comparative  healthfulness  throughout  the  State,  and  that 
the  more  intelligent  citizens,  and  those  who  have  the  most  to  do  with  the 
moulding  of  public  opinion,  are  more  and  more  realizing  that  the  health 
of  the  people  is  a  vital  consideration  as  to  the  public  prosperity.  The  sub- 
ject of  water  supply  is  briefly  considered  in  the  report  of  the  able  secretary, 
Dr.  E.  M.  Hunt,  and  the  statement  made,  that  whilst  pure  water  has  been 
obtained  by  bored  wells  driven  under  skilled  advice,  in  several  of  the  more 
important  sea-side  resorts,  such  as  Cape  May  and  Asbury  Park,  much  foul 
water  is  still  imbibed.  Within  thirty  miles  of  New  York  City  is  to  be 
found  half  the  population  of  the  State  of  New  Jersey.  Of  this  number, 
accordii  to  the  careful  and  discriminating  judgment  of  engineers,  chem- 
ists, ph;  icians,  and  boards  of  health,  not  one-half  are  supplied  with  water 
fit  to  drink.  In  regard  to  the  important  question  of  the  disposal  of  house 
waste  by   mptying  it  into  streams,  a  remarkable  experiment  has  been  tried 


1885.] 


Health  Reports. 


525 


at  Newark,  where  an  effort  was  made  to  collect  the  sewage  in  a  ditch,  and 
then  by  the  aid  of  water  impounded  at  high  tide,  to  wash  it  out  as  the  tide 
fell.  This  attempt,  carried  out  at  an  expense  of  $75,000,  utterly  failed,  as 
had  been  predicted  by  Dr.  Hunt.  The  attention  of  the  Board  has  been 
more  than  ever  turned  to  effluvium  nuisances,  and  it  is  urged  that  foul 
odors  from  pig-pens,  slaughter-houses,  bone-boiling  works,  and  other  offen- 
sive factories,  should  not  be  allowed  to  escape  within  several  hundred  feet 
of  dwellings.  The  secretary  asserts,  as  an  ascertained  fact,  that  nausea, 
diarrhoea,  and  an  extra  demand  for  vital  force,  are  the  results  in  many 
cases,  and  that  when  some  special  contagion  alights  or  an  epidemic  occurs, 
the  districts  nearest  to  such  odors,  and  especially  persons  who  are  newly 
brought  in  contact  with  them,  are  most  likely  to  suffer  severely.  The 
dealing  with  petroleum  sludge  in  order  to  recover  from  it  the  sulphuric 
acid,  and  the  use  of  crude  sludge  for  the  manufacturing  of  fertilizers,  also 
occasion  much  nuisance,  which  lias  been  partially  mitigated  by  the  efforts 
of  the  Board.  The  authorities  have  been  duly  alive  to  the  important  sub- 
jects of  the  hygiene  of  schools  and  penal  institutions,  in  which  careful  in- 
spections have  been  made  and  judicious  changes  recommended. 

Several  pages  are  devoted  by  Dr.  Hunt  in  his  general  report  to  Cholera 
and  Precautions  Against  it.  Since  it  is  not  deemed  probable  that  the 
United  States  will  escape  invasion  by  cholera  another  year,  he  advises 
that  water  supplies  and  pipes,  etc.,  for  removal  of  waste  should  be  at  once 
inspected,  and  any  faults  therein  corrected.  Also,  that  personal  cleanli- 
ness should  be  strictly  enjoined.  Arrangements  ought  to  be  made  for 
promptly  reporting  the  first  case  in  any  locality  in  order  that  thorough  iso- 
lation and  disinfection  shall  immediately  be  practised.  As  an  encourage- 
ment to  diligent  attention  in  this  respect,  it  may  be  stated  that  in  four 
late  epidemics  in  India  there  were  154,986  villages  attacked.  But  in 
58,972  of  these  there  was  only  one  death,  and  in  20,596  there  were  only 
two  deaths.  Yet  the  fact  that  in  these  years  the  total  mortality  from 
cholera  in  India  was  1,380,226  shows  how  fearfully  destructive  it  is  when 
it  finds  all  the  requisite  conditions,  or  is  not  guarded  by  efficient  sanitary 
police. 

The  first  essay  is  one  contributed  by  E.  H.  Janes,  M.D.,  Assistant 
Sanitary  Superintendent  of  the  Health  Department  of  the  city  of  New 
York,  on  What  Legislation  is  Desirable  for  the  Improvement  of  Tenement 
Houses,  and  contains  some  excellent  suggestions  in  regard  to  ameliorating 
the  miseries  of  the  poor  creatures  who  inhabit  these  foul  and  dangerous 
dwellings.  The  next  article  on  "  Water  supply,"  by  the  Secretary,  Dr. 
E.  M.  Hunt,  is  filled  with  judicious  advice  which  is  now,  in  view  of  a 
cholera  epidemic,  doubly  important.  The  frequent  testing  of  drinking 
water  is  especially  urged,  and  the  convenient  Heinsch's  test  for  sewage 
contamination  recommended  as  follows  :  Fill  a  clean  pint  bottle  to  three- 
fourths  of  its  capacity  with  the  water  to  be  tested,  dissolve  in  it  half  a  tea- 
spoonful  of  pure  white  loaf  or  granulated  sugar,  and  keep  it  in  a  warm 
place  for  two  days.  If  before  the  end  of  that  time  the  fluid  becomes 
cloudy  or  milky  it  should  be  rejected,  whilst  if  on  the  contrary  it  remains 
clear  for  forty-eight  hours,  it  is  probably  fit  for  domestic  use.  In  an  in- 
teresting essay  on  Filtration,  by  Prof.  George  H.  Cook,  the  author  main- 
tains that,  whilst  the  benefits  arising  from  the  filtration  of  water  have 
been  proved  by  many  satisfying  experiments,  the  chemical  or  mechanical 
changes  which  it  undergoes  are  not  well  understood.  Analyses  of  water 
before  and  after  filtration  generally  show  a  small  diminution  in  the 
No.  CLXXVIII  April,  1885.  34 


526 


Reviews. 


[April 


amounts  of  organic  matter,  not,  however,  by  any  means  sufficient  to  ex- 
plain the  improvement  which  appears  to  have  taken  place  in  the  properties 
of  the  fluid.  Dr.  Hunt,  in  his  useful  Notes  upon  Popular  Health  Resorts, 
gives  an  encouraging  account  of  the  progress  in  local  sanitation  made 
during  the  past  six  years,  and  furnishes  data  in  regard  to  the  present  con- 
dition of  various  watering-places  which  it  would  be  well  for  every  physician 
to  consult  before  sending  patients  to  the  many  invaluable  resorts  upon  the 
New  Jersey  coast.  "We  are  glad  to  see  that  Prof.  Albert  H.  Leeds,  Chair- 
man of  the  Committee  of  Analysts,  in  his  general  report  renews  his  ex- 
pression of  confidence  in  the  legal  standard  of  12  per  cent,  total  solids  for 
pure  milk,  and  is  still  of  the  opinion  that  to  debase  this  standard  would 
be  to  legalize  the  traffic  in  watered  milk.  Methods  of  Butter  Analysis,  by 
Prof.  H.  B.  Cornwall,  is  an  elaborate  review  of  the  questions  involved,  in 
which  the  author  concludes  that  Reichert's  modification  of  Hehner's  plan 
for  determining  the  fatty  acids  is  the  only  one  yet  devised  which  is  capa- 
ble with  any  practical  degree  of  accuracy  of  distinguishing  between  cocoa- 
nut  oil  in  mixtures  or  alone,  and  pure  butter  fat.  Reprints  of  circulars 
and  laws  relating  to  health,  with  elaborate  statistical  tables,  conclude  the 
volume,  which,  as  usual,  forms  a  valuable  addition  to  the  working  library 
of  any  practical  sanitarian.  J.  G.  R. 


Art.  XXV  The  International  Encyclopcedia  of  Surgery.  A  Sys- 
tematic Treatise  of  the  Theory  and  Practice  of  Surgery  by  Authors  of 
Various  Nations.  Edited  by  John  Ashhurst,  Jr.,  M.D.,  Professor  of 
Clinical  Surgery  in  the  University  of  Pennsylvania.  Vols.  IV.  and  V. 
8vo.  pp.  xxiii.  987,  xxxvi.  1207.  New  York  :  William  Wood  &  Co., 
1884. 

Volume  IV.,  with  the  exception  of  an  article  on  Tumors,  is  devoted  to  the 
bones,  and  claims  more  particularly  the  attention  of  the  general  surgeon. 
The  authors  are  but  few  in  number,  but  are  all  men  whose  names  are  well 
known  both  in  this  country  and  Great  Britain,  and  it  is  a  matter  of  con- 
gratulation that  the  important  subjects  with  which  they  deal  have  not  been 
compressed  into  the  narrow  limits  usually  found  necessary  to  keep  a 
work  of  this  kind  within  bounds.  Even  here,  one  feels  that  the  authors 
have  had  none  too  much  room,  the  tendency  of  large  works  of  reference 
like  this  in  the  English  language  being  in  the  direction  of  too  great  con- 
densation ;  a  fault  in  agreeable  contrast  with  the  prolixity  of  continental 
works,  but  one  nevertheless  too  frequently  noticed  by  those  who  have  occa- 
sion to  study  the  literature  of  a  given  subject. 

The  opening  articles  is  upon  Injuries  of  Bones,  and  is  from  the  pen  of 
a  writer  whose  name  is  intimately  associated  with  that  subject  in  this 
country — Dr.  John  H.  Packard.  This  is  not  a  department  in  which  any 
recent  triumphs  are  to  be  recorded,  and  the  task  of  the  author  consists 
chiefly  in  carefully  digesting  and  assimilating  the  experiences  of  the  pro- 
fession in  certain  modes  of  treatment  which  have  had  an  opportunity  of 
enjoying  an  extended  trial. 

We  are  glad  to  see  that  he  ranges  himself  upon  the  side  of  those  who 
do  not  regard  the  plaster  bandage  as  the  sum  and  substance  of  the  treat- 
ment of  fractured  bone,  and  that  he  recognizes  the  necessity  which  all 
severely  injured  parts  feel  for  rest.    "  Fractures  of  the  lower  extremity, 


1885.] 


The  International  Encyclopaedia  of  Surgery. 


527 


as  a  general  rule,  involve  a  long  confinement  to  bed,"  is  an  opinion 
which  a  few  years  ago  could  not  have  found  favor  with  surgeons  of  pro- 
gressive tendencies  ;  but  we  think  a  further  trial  of  the  early  stiff  ban- 
dage treatment  has  been  followed  by  a  considerable  diminution  in  the 
number  of  its  advocates.  It  possesses  the  great  disadvantage  of  conceal- 
ing changes  upon  the  surface  which  develop  with  the  first  inflammatory 
reaction,  and  sometimes  become  most  important  factors  in  the  treatment 
of  the  case.  Although  an  excellent  extension  and  counter-extension  can 
undoubtedly  be  maintained  in  this  way,  lateral  motion  cannot  surely  be 
prevented,  and  considerable  deformity  thus  becomes  possible  as  the  limb 
shrinks  and  becomes  loosened  in  its  casing.  This  is  particularly  true  of 
fractures  of  the  forearm  and  elbow,  which  have  been  treated  with  some 
of  the  numerous  forms  of  material  which  are  moulded  to  the  part.  The 
author  is  an  advocate  of  passive  motion,  which  he  specially  dwells  upon  in 
the  treatment  of  fracture  of  the  elbow-joint.  This  is  in  opposition  to  the 
views  of  one  of  our  most  prominent  authorities  in  this  country.  The  old- 
fashioned  method,  which  consisted  in  pumping  a  joint  for  some  weeks 
immediately  following  the  removal  of  the  splints,  has,  we  presume,  few 
supporters  to-day.  The  great  majority  of  joints  that  have  been  well  set 
and  cared  for  can,  with  proper  directions  for  exercise,  be  intrusted  to 
the  patient  or  to  the  masseur.  There  are,  however,  certain  joints,  like  the 
shoulder  and  the  humeral  end  of  the  radius,  whose  work  can  to  a  certain 
extent  be  done  for  them,  as  in  rotation,  and  in  which  anchylosis  is  more 
liable  consequently  to  become  permanent.  We  have  seen  several  cases 
where  rotation  of  the  radius  was  lost  after  fracture  at  the  elbow-joint,  in 
which  no  injury  to  the  radius  had  occurred.  Early  attention  to  the 
movements  of  the  bone  must  have  obviated  this.  On  the  other  hand,  flexion 
of  the  elbow  will  surely  return  without  a  particle  of  passive  motion,  if 
the  condyles  have  been  kept  in  their  proper  places.  In  reading  that  por- 
tion of  the  article  devoted  to  fractures  of  the  upper  portion  of  the  femur, 
we  were  surprised  to  see  so  little  said  about  one  of  the  most  common  forms 
of  injury  of  this  region,  namely,  impacted  fracture  of  the  neck  into  the 
trochanter.  There  is  the  usual  discussion  of  the  intra-capsular  and  extra- 
capsular fractures,  which  seems  to  us  to  have  no  very  important  practical 
bearing.  How  often  does  one  meet  with  an  ununited  fracture  of  the  neck 
of  the  femur?  On  the  other  hand,  the  impaction  which  occurs  when  old 
people  fall  upon  their  trochanter  is  often  passed  unrecognized,  or,  if  dis- 
covered, is  subjected  to  an  unnecessarily  long  and  tedious  treatment. 

As  to  the  different  varieties  of  splints  advised  in  the  treatment  of  frac- 
ture we  have  little  to  say;  every  man  works  best  wTith  his  own  tools,  and 
although  we  should  not  in  all  cases  imitate  the  author,  we  can  cordially 
recommend  his  advice  as  being  based  upon  sound  principles  ;  we  should 
have  been  glad  to  see  a  little  more  space  devoted  to  the  subject  of  the 
treatment  of  union  with  deformity,  the  operations  for  subcutaneous  oste- 
otomy, the  wiring  of  bones  for  non-union,  but  we  presume  the  exigencies  of 
the  case  precluded  a  more  extended  treatment  of  these  subjects. 

The  article  on  Diseases  of  the  Joints  is  by  Mr.  Richard  Barwell,  of 
London,  already  favorably  known  to  readers  of  the  Encyclopaedia  in  con- 
nection with  aneurism.  This  is  a  learned  and  carefully  prepared  chapter. 
The  author  divides  joint  disease  into  simple,  dry,  suppurative,  strumous, 
rheumatic,  and  gouty  synovitis ;  the  articular  forms  of  osteitis,  and  affec- 
tions of  the  joint  due  to  syphilis  and  nerve  disease.  Hip  disease  is  treated 
separately  from  the  other  forms  of  strumous  disease,  presumably  for  the 


528 


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[April 


purpose  of  bringing  the  discussion  of  mechanical  treatment  at  the  end  of 
the  article;  but  this  arrangement  disregards  scientific  accuracy,  and  is  not 
wholly  in  keeping  with  the  dignity  of  the  work.  The  most  interesting 
section  to  surgeons  is  that  part  devoted  to  anchylosis,  which,  however,  is 
exceedingly  brief ;  much  too  brief,  we  think,  to  serve  as  an  accurate 
guide  for  those  intending  to  perform  some  of  the  newly  devised  operations 
of  osteotomy.  The  author's  method  of  treating  anchylosis  of  the  knee- 
joint  by  section  through  the  condyles  of  the  femur,  and  in  some  cases 
through  the  head  of  the  tibia  and  fibula,  is  of  especial  interest,  and  seems 
to  promise  more  than  any  other  of  the  numerous  methods  that  have  been 
brought  forward.  This  question  of  osteotomy  has  become  so  important  a 
one,  and  so  many  operations  have  been  devised  for  each  joint  as  well  as 
for  bone  deformity,  that  a  separate  article  on  this  subject  would  have  been 
a  very  valuable  feature  of  the  work.  We  note  that  Mr.  Barwell  no 
longer  employs  Lister's  dressing  or  the  spray,  the  dressing  being  found  too 
clumsy  for  accurate  adaptation  of  the  plaster  bandage,  but  his  substitute 
is  none  the  less  founded  on  careful  antiseptic  principles.  He  has  a  special 
predilection  in  favor  of  boro-glyceride. 

The  sections  on  Neuroses  of  the  Joints  and  the  Arthropathies  are  of 
special  interest. 

When  resection  was  substituted  for  amputation  in  injuries  and  diseases 
of  the  joints,  it  was  thought  that  one  of  the  greatest  advances  in  modern 
surgery  had  been  achieved.  During  the  past  quarter  of  a  century  this 
operation  has  had  a  most  extensive  trial.  Many  improvements  and  modi- 
fications have  been  introduced,  most  of  which  have  been  designed  for  the 
purpose  chiefly  of  securing  a  still  greater  economy  in  the  preservation  of 
parts.  This  conservative  tendency  has  shown  itself  latterly  in  a  reaction 
in  certain  quarters  against  the  operation  itself  as  involving  an  unnecessary 
sacrifice  of  portions  of  the  joint  which  have  not  been  subjected  to  injury 
or  disease,  and  it  has  been  even  boldly  asserted  that  resection  of  joints  as 
at  present. practised  would  soon  become  an  operation  of  the  past. 

The  carefully  prepared  article  by  the  editor  of  this  work,  Professor 
Ashhurst,  embracing  statistical  tables,  and  many  cases  with  results  con- 
tributed by  the  author,  is  valuable  testimony  in  favor  of  the  operation. 
His  views  on  this  question  may  be  summarized  by  a  quotation  from  his 
comments  upon  certain  substitutes  proposed  for  excision  of  the  knee, 
which  consist  either  in  application  of  mineral  acids  to  the  diseased 
portions  of  the  articulation,  or  in  laying  open  the  joint  and  scraping 
away  the  diseased  structures.  He  says :  "  But  the  results  of  these  methods 
have  not  been  uniformly  favorable,  and  excision  has  been  found  so 
satisfactory  in  my  own  hands  that  I  have  not  felt  tempted  to  abandon  a 
tried  and  proved  operation  for  a  procedure  which,  at  best,  has  not  as  yet 
been  shown  to  be  an  improvement."  He  does  not  hesitate,  however,  to 
content  himself  with  removing  a  very  thin  layer  of  bone  with  the  saw, 
"and  then  to  attack  any" remaining  patches  of  caries  or  necrosis  with  the 
gouge,  osteotrite,  or  trephine." 

Excision  of  the  hip-joint  is  perhaps  as  unlikely  to  be  attended  by  a 
favorable  result  as  that  of  any  other  joint,  the  mortality  being  chiefly  due 
to  constitutional  conditions,  as  the  author  shows.  He  is,  however,  able  to 
present  several  favorable  results,  one  in  a  patient  twenty-one  years  of  age, 
and  another  of  double  excision  being  especially  worthy  of  mention. 

The  amount  of  bone  which  should  be  removed  depends  in  part  upon 
the  amount  of  disease,  but  also  on  the  necessity  for  drainage.  Removal 


1885.] 


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529 


of  a  portion  of  the  trochanter  may  thus  become  necessary  in  order  to 
make  possible  the  healing  of  a  pus  cavity  forming  about  the  head  of  the 
bone.  So  with  the  malleoli  in  excision  of  the  ankle-joint,  it  becomes 
necessary  to  sacrifice  sound  bone  to  leave  the  part  in  a  shape  favorable 
for  repair.  In  reading  statistics  of  this  class  of  operations  it  is  important 
to  have  a  thorough  understanding  about  the  age  of  the  patient  in  order 
to  estimate  the  operation  at  its  proper  value.  The  prognosis  of  resection 
in  a  child  may  be  couleur  de  rose,  and  the  result  of  the  same  operation  in 
the  adult  most  disastrous.  This  is  perhaps  more  true  of  the  ankle  than 
in  any  other  joint.  Professor  McLeod,  of  Glasgow,  once  asserted  in  our 
hearing,  in  the  most  categorical  manner,  that  resection  of  this  joint  for 
caries  in  the  adult  was  never  successful,  and  we  are  beginning  to  come 
round  to  that  opinion  after  a  considerable  experience.  On  the  other 
hand,  with  what  pride  does  the  medical  periodical  writer  point  to  a  row 
of  little  patients  who  have  undergone  the  ordeal !  The  results  are,  as  a 
rule,  most  excellent,  but  there  is  always  the  prospect  of  cure  in  these 
cases  without  operative  interference.  Decidedly  we  have  not  yet  got  at 
the  "  bottom  facts"  of  this  operation.  Dr.  Fen  wick's  method  of  excising 
the  knee-joint  by  cutting  a  groove  in  the  head  of  the  tibia,  into  which  the 
pared  condyles  of  the  femur  are  set,  a  very  ingenious  operation,  is 
described  in  a  chapter  by  itself.  A  table  of  twenty-eight  cases  gives  but 
one  death  and  two  amputations,  but  it  should  be  stated  that  no  patient 
was  over  fourteen  years  of  age. 

We  looked  with  considerable  interest  to  the  chapter  on  Tumors,  for  in 
English  publications  this  department  of  a  surgical  work  is  usually  one  of 
the  weakest  points  ;  this  cannot  be  said  in  the  present  case,  for  Mr.  Butlin, 
of  St.  Bartholomew's  Hospital,  has  produced  an  article  of  high  quality,  and 
eminently  well  adapted  to  the  Encyclopcedia.  We  are  glad  to  see  that  St. 
Bartholomew's  has  among  its  present  generation  of  surgeons  a  successor 
to  the  work  so  brilliantly  begun  by  Sir  James  Paget.  The  author  makes 
some  interesting  observations  on  the  theory  of  the  parasitic  origin  of 
tumors.  He  calls  attention  to  the  close  resemblance  of  the  processes  of 
the  malignant  tumors  to  those  of  certain  of  the  infection  tumors,  espe- 
cially tubercle ;  to  the  objection  that  tumors  are  not  inoculable,  he  states 
that  probably  the  difficulty  of  carrying  out  inoculation  experiments  suc- 
cessfully is  much  greater  than  is  usually  supposed.  Anyone  who  has 
read  the  recent  investigations  of  Ogston  and  Rosenbach  on  the  micrococci 
of  pus,  will  have  some  idea  of  the  character  of  the  obstacles  to  success,  and 
wiry  the  experiments  hitherto  made  may  not  have  succeeded.  The  ex- 
ceedingly interesting  observations  on  the  development  of  lympho-sarcoma 
in  the  lungs  of  the  cobalt  miners  of  Schneeberg,  and  the  immunity  of  all 
persons  in  the  neighborhood  not  employed  in  the  pit ;  the  researches  of 
Haviland  on  the  geographical  distribution  of  cancer — all  help  to  prepare 
one  for  the  statement  that  "  the  rapid  advance  in  the  knowledge  of  micro- 
organisms will  lead,  ere  long,  to  the  discovery  of  tumor  parasites."  The 
classification  adopted  is  the  anatomical  one.  They  are  divided  into  two 
great  groups,  the  connective  tissue  and  the  epithelial  tumors.  This  plan 
will  undoubtedly  survive  all  other  improvements  until  some  great  dis- 
covery like  that  which  we  have  just  hinted  at  will  let  in  a  flood  of  light 
upon  their  origin  and  the  laws  which  govern  their  development. 

Mr.  Butlin  divides  lymphatic  tumors  into  two  varieties,  the  lympho-sar- 
coma and  the  lymph-adenoma,  or  Hodgkin's  disease.  As  both  of  these  are 
malignant,  it  seems  curious  that  the  author  should  see  fit  to  separate  them, 


530 


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and  yet  fail  to  recognize  the  existence  of  a  pure  lymphoma,  or  an  hyper- 
trophy of  the  gland  of  a  benign  character.  The  hospital  surgeon  certainly 
meets  with  growths  that  cannot  be  called  scrofulous  or  tubercular,  and  at 
the  same  time  have  no  malignant  tendencies.  Whatever  the  etiology  of 
such  a  growth  may  eventually  prove  to  be,  we  shall  find  it  most  conve- 
nient in  the  mean  time  to  recognize  such  a  variety. 

That  portion  of  the  article  devoted  to  carcinoma  is  of  special  merit;  the 
rarer  forms  of  cancer  of  the  breast,  as  Paget's  disease  and  true  scirrhus, 
are  represented  in  two  very  perfect  plates ;  portraits  are  also  given  of  two 
cases  of  rodent  ulcer.  The  following  quotation  will  show  that  the  author 
is  fully  abreast  of  the  times  in  his  views  on  the  treatment  of  cancer  : — 

"But  those  who  expect  most  from  the  operation  sweep  the  tumor  and  the 
breast  completely  off,  together  with  a  very  wide  area  of  integument,  and  not 
content  with  removing  axillary  glands  which  are  decidedly  enlarged,  search  the 
axilla  when  no  enlargement  can  be  felt,  and  remove  all  the  glands  which  can  be 
found." 

The  contribution  on  Injuries  of  the  Bach,  by  the  late  Dr.  John  S. 
Lidell,  is,  like  his  work  already  noticed  in  a  previous  volume,  of  the 
highest  order  of  excellence.  It  is  characterized  not  only  by  the  collection 
of  a  large  number  of  interesting  cases  drawn  from  the  writer's  own  expe- 
rience, but  by  a  critical  study  also  of  the  work  of  others,  among  whom 
may  be  especially  mentioned  Hilton  and  Erichsen.  The  work  of  Page 
on  the  railway  spine  had  not,  at  the  time  of  writing,  appeared,  and  the 
reaction  which  has  since  set  in  against  the  views  of  Erichsen  had  not 
consequently  manifested  itself  sufficiently  to  demand  the  notice  which  it 
would  now  obtain  in  an  article  on  this  subject.  In  every  other  way  the 
work  done  by  the  writer  is  of  the  most  thorough  and  modern  type.  We 
have  found  the  sections  on  sprains,  twists,  and  wrenches  of  the  back  most 
valuable  and  interesting  reading.  Such  writings  are  of  the  greatest  assist- 
ance to  the  surgeon  in  clearing  up  the  diagnosis  of  many  obscure  forms  of 
injury.  The  views  of  the  author  on  the  neuropathic  origin  of  bed-sores 
forming  after  some  of  this  class  of  injuries,  and  of  inflammation  of  the 
kidneys  and  bladder,  deserve  particular  attention.  In  the  portion  devoted 
to  gunshot  injuries,  the  great  experience  of  the  author  in  the  department 
of  military  surgery  is  shown  to  the  best  advantage.  We  must  also  say  a 
word  of  praise  for  the  excellent  literary  style  which  pervades  the  work  of 
this  writer. 

The  volume  concludes  with  a  chapter  on  Malformations  and  Diseases 
of  the  Spine,  by  Mr.  Frederick  Treves,  of  the  London  Hospital.  This 
includes  congenital  tumors,  the  various  curvatures,  including  Pott's  dis- 
ease. The  text  of  this  article  is  of  good  quality,  but  there  is  a  deficiency 
of  illustrations  in  subjects  where  illustrations  might  have  been  used  to 
great  advantage,  and  when  some  departure  from  the  beaten  track  might 
have  been  attempted.  There  is  indeed  little  to  criticize  unfavorably  in 
this  volume,  which  is  fully  up  to  the  standard  of  its  predecessors. 

We  come  now  to  a  volume  which  will  probably  be  read  by  a  larger  num- 
ber of  physicians  than  any  of  the  others,  containing  as  it  does  the  more 
strictly  regional  department  of  surgery.  There  are  no  less  than  fourteen 
contributors,  among  whom  we  regret  not  to  be  able  to  find  a  single  Con- 
tinental writer ;  not,  indeed,  on  account  of  the  quality  of  the  work,  for 
the  high  standard  which  has  been  preserved  makes  this  volume  one  of  the 
most  interesting  of  the  series,  but  because  the  original  design  of  the  pub- 
lishers in  bringing  together  the  writers  of  France  and  Germany  with 


1885.]  The  International  Encyclopaedia  of  Surgery. 


531 


those  of  England  and  America,  might  have  been  more  fully  carried  out. 
At  least  the  work  of  one  French  writer  is  promised  in  the  final  volume, 
and  we  trust  the  list  of  authors  will  prove  to  be  more  in  keeping  with  the 
title. 

The  opening  article  is  upon  Injuries  of  the  Head,  by  Dr.  Charles  B. 
Nancrede,  of  Philadelphia.  This  is  not  an  easy  subject  to  write  about, 
not  only  for  its  inherent  difficulties,  but  on  account  of  the  very  long  list 
of  eminent  writers  who  seem  to  have  exhausted  the  field.  The  author, 
however,  has  had  the  talent  to  infuse  originality  into  his  treatment  of  a 
hackneyed  theme.  There  is  a  liberal  quotation  of  instructive  cases,  in- 
cluding many  of  personal  experience.  We  shall  allude  to  but  two  points 
in  this  valuable  article.  In  regard  to  the  nature  of  concussion,  the  writer 
ranges  himself  with  those  who  believe  that  there  is  probably  no  such  thing 
as  "  cerebral  vibration  without  visible  lesion,"  and  he  feels  strengthened 
in  this  view  by  the  observations  of  Duret  on  the  pressure  exerted  by  the 
intra-ventricular  fluid,  and  the  concurrent  vaso-motor  changes.  A  rup- 
ture in  the  floor  of  the  fourth  ventricle  or  a  vascular  disturbance  may  be 
detected  when  no  actual  extravasations  of  blood  have  taken  place.  We 
would,  however,  call  attention  to  the  fact,  that  later  German  writers 
(Groeningen  and  Blumenstoch)  have  not  confirmed  these  observations, 
and  that  the  former  of  these  two  authors  states  that  the  most  marked 
symptoms  of  concussion  can  occur  without  the  discovery  of  lesion  by  the 
most  careful  post-mortem  examination.  Thus,  with  the  lapse  of  time,  old 
theories  once  more  have  become  fashionable. 

The  sudden  notoriety  which  the  fissure  of  Rolando  has  attained  natu- 
rally draws  attention  to  that  part  of  the  article  which  treats  of  the  locali- 
zation of  cerebral  lesion,  and  we  are  glad  to  be  able  to  record  that  the 
author  cannot  be  accused  of  having  been  caught  napping  upon  this  depart- 
ment of  his  subject.  Careful  directions  are  given  for  determining  the 
seat  of  the  injury  in. the  various  combinations  of  paralysis.  We  give  the 
concluding  remarks  upon  this  interesting  question  : — 

"I  would  remark  that  the  whole  subject  of  cerebral  localization  is  yet  in  its 
infancy  ;  that  what  has  been  said  must  be  considered  as  provisional ;  but  that  by 
the  light  already  gained,  a  few  surgeons  have  succeeded  in  operations,  solely 
guided  by  cerebral  topography,  while  more  have  been  partially  guided,  as  I  have 
seen  in  two  instances  ;  and  that  in  the  past,  operations  have  been  refrained  from, 
and  still  more  will  be  in  the  future,  which  a  knowledge  of  cerebral  localization 
may  show  to  be  useless." 

Dr.  Albert  H.  Buck,  of  New  York,  has  contributed  an  article  on 
Injuries  and  Diseases  of  the  Ear.  It  is  handsomely  illustrated  by  chromo- 
lithographic  plates,  copied  from  Politzer.  It  is  of  a  most  practical  char- 
racter  and  admirably  adapted  to  the  wants  of  the  general  practitioner,  as 
we  can  testify  from  personal  experience.  There  is  a  clearness  and  sim- 
plicity of  style  which  enable  one  to  find  easily  the  information  one  desires 
to  obtain. 

An  equally  valuable  article,  and  one  covering  ground  in  which  the 
surgeon  is  more  directly  interested,  is  that  which  follows  on  Diseases  and 
Injuries  of  the  Nose  and  its  Accessory  Sinuses,  by  Dr.  George  M. 
Lefferts,  of  New  York.  One  of  the  affections  of  this  cavity,  for  which 
the  general  surgeon  is  usually  consulted,  is  deviation  of  the  septum.  We 
have  therefore  turned  with  some  interest  to  the  remarks  of  the  writer  on 
the  management  of  this  deformity,  but  are  somewhat  disappointed  not  to 
find  a  critical  estimate  of  the  various  methods  which  have  been  proposed. 


532 


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He  has  contented  himself  with  a  simple  enumeration,  but  as  he  points 
out  the  disagreeable  effects  of  a  resulting  artificial  perforation,  and 
speaks  of  good  results  attending  persistent  dilatation  of  the  narrowed 
cavity,  we  are  led  to  infer  that  he  is  disposed  to  favor  the  milder  and 
earlier  method  of  treatment  to  the  many  ingenious  forms  of  operation 
which  have  lately  been  proposed.  Another  interesting  feature  of  this 
article  is  the  section  on  naso-pharyngeal  polypi.  We  had  supposed  that 
the  success  attending  Lincoln's  use  of  the  galvano-cautery  loop  had  brought 
this  method  into  favor,  at  the  expense  of  the  more  heroic  forms  of  osteo- 
plastic resection  of  the  jaw.  A  very  concise  summary  is  presented  of 
these  different  methods,  the  preference  being  given  to  partial  excision 
of  the  jaw,  an  operation  which  removes  the  palatine  portion,  but  leaves 
the  orbital  and  malar  portions  of  the  bone.  The  advantages  claimed 
for  this  method  are  the  removal  of  that  part  of  the  bone  from  which 
these  growths  frequently  spring,  the  turbinated  bone,  and  the  subse- 
quent accessibility  of  the  parts  to  operative  measures,  in  case  of 
recurrence.  These  tumors  vary  considerably  in  their  clinical  characters 
from  benign  forms  to  decidedly  malignant  types.  To  the  latter  variety 
belong  the  sarcomatous  growths,  springing  from  the  spheno-maxillary 
fossa,  for  which  Langenbeck  devised  his  admirable  osteoplastic  resection 
of  the  jaw,  which  enables  the  surgeon  to  get  at  the  various  ramifica- 
tions. The  more  benign  form  may,  on  the  other  hand,  be  easily  reached 
and  removed  by  the  platinum  wire,  even  without  ether  or  cocaine,  and 
what  is  more  important  still,  without  deformity.  A  tendency  to  return 
may  be  controlled  by  subsequent  applications  of  the  galvano-cautery. 
Should  the  disease  still  prove  obstinate,  we  have  still  the  resection  or 
excision  to  fall  back  upon.  It  should  not  be  forgotten  (a  point  by  the 
way  we  believe  the  author  has  not  alluded  to),  that  after  the  twenty-fifth 
year  this  somewhat  mysterious  polyp  which  favors  the  male  youth  not 
infrequently  disappears  spontaneously. 

An  admirable  sequence  to  this  chapter  is  that  on  the  Mouth  and  Jaw* 
by  Mr.  Christopher  Heath.  We  are  disposed  to  criticize  one  or  two 
points,  however,  in  this  article.  In  the  operation  of  removal  of  the  tongue 
those  methods  are  chiefly  recommended  which  regard  it  as  an  erectile 
organ,  whose  bleeding  vessels  cannot  be  controlled.  We  are  advised  to 
try  some  of  the  various  methods  of  applying  the  ecraseur.  We  had 
supposed  that  Whitehead's  operation  had  shown  the  inferiority  of 
methods  based  on  any  such  assumption,  but  we  do  not  find  the  latter 
name  even  mentioned.  We  are  aware  that  no  man  is  a  prophet  in  his 
own  country,  and  it  may  be  that  distance  has  lent  enchantment  to  our 
view,  but  the  idea  of  regarding  this  organ  equally  adapted  to  certain 
surgical  principles  of  treatment  with  many  other  parts  of  the  body, 
appeals  strongly  to  the  mind.  The  problem  appears  to  us  to  lie  in 
the  management  of  the  parts.  If  an  open  mouth  and  position  favorable 
for  drainage  of  blood  be  secured,  in  a  manner  to  be  relied  upon,  the 
operation  is  robbed  of  its  terrors,  and  this,  it  appears  to  us,  is  what 
Whitehead  has  accomplished.  With  this  certainty  in  the  mind  one  can 
deliberately  remove  with  scissors  and  forceps  such  portions  as  may  be 
desired,  taking  up  vessels  if  necessary,  as  elsewhere.  Travellers  in  the 
East  still  speak  of  men  whose  tongues  have  been  cut  out  as  a  punishment, 
and  who  remain  as  proof  that  hemorrhage  from  this  organ,  even  when 
left  to  nature,  is  not  fatal. 

In  speaking  of  the  operation  for  cleft  palate,  the  writer  leaves  it  to  be 


1885.] 


The  International  Encyclopaedia  of  Surgery. 


533 


inferred  that  good  results  may  be  obtained  in  articulation,  with  practice. 
This  is  an  error  which  Kingsley  points  out  in  the  following  chapter.  We 
fail  to  understand  why  the  latter  writer,  whose  name  is  so  intimately 
connected  with  the  mechanical  treatment  of  this  deformity,  has  contented 
himself  with  referring  in  a  few  general  terms  to  the  different  kinds  of 
apparatus.  A  work  like  this  should  certainly  be  supplied  with  illustra- 
tions of  some  of  the  more  successful  forms  of  obturators,  which  constitute 
so  distinct  an  advance  in  treatment.  There  is,  perhaps,  a  lack  of  that 
surgical  enthusiasm  which  animates  the  other  writers  of  this  volume. 

The  name  of  Dr.  George  H.  B.  Macleod,  Professor  of  Surgery  in  the 
University  of  Glasgow,  gives  an  additional  interest  to  the  article  on  the 
Neck,  of  which  he  is  the  author.  This  is  a  part  of  the  body  unusually 
difficult  to  write  about,  owing  to  the  heterogeneous  nature  of  the  topics  to 
be  described,  and  the  difficulty  of  treating  them  properly,  without  tres- 
passing upon  neighboring  regions.  It  is  hardly  fair  to  criticize  an  article 
which  has  been  necessarily  much  condensed,  as  this  doubtless  has  been ; 
this  may,  however,  be  an  appropriate  place  to  call  attention  to  the  oppor- 
tunity which  offers  itself  to  the  author,  who  may  contemplate  writing  con- 
cerning this  region  on  some  future  occasion,  to  depart  from  conventional 
methods  and  handle  his  subject  in  a  manner  both  original  and  much 
more  interesting.  The  topographical  anatomy  of  the  neck  should  be  one 
of  the  important  features  of  such  an  article.  Something  of  this  sort  has 
already  been  attempted  by  Konig,  and  might  greatly  be  improved 
upon.  Nothing  could  be  of  more  value  to  the  surgeon  than  a  thorough 
knowledge  of  the  spaces  in  which  pus  burrows,  and  the  routes  which  it 
habitually  takes.  A  study  of  the  development  of  the  neck,  which  throws 
light  upon  the  origin  of  cysts  and  fistulas,  caused  by  an  imperfect  closure 
of  the  bronchial  clefts,  is  omitted  here,  as  is  usual  in  English  and 
American  articles,  and  is  of  great  practical  value  as  an  aid  to  the 
diagnosis  and  treatment  of  the  so-called  hydrocele  of  the  neck.  It  is  but 
fair  to  say  that  our  author  is  evidently  familiar  with  the  literature  of  the 
subject,  but  is  satisfied  to  dismiss  it  with  this  remark :  "  Notwith- 
standing the  ample  discussion  which  this  point  has  undergone,  little 
reliable  light  has  yet  been  thrown  upon  it,  and  consequently  it  would  be 
fruitless  to  dwell  upon  it  further."  These  criticisms  pertain,  however, 
to  a  small  portion  of  this  article,  which  bears  throughout  the  flavor  of  an 
operator  and  writer  of  long  experience.  The  portion  devoted  to  tumors  is 
of  great  practical  value,  and  has  many  new  and  valuable  illustrations, 
the  discussion  of  the  treatment  of  tumors  of  the  thyroid  gland  being 
particularly  good.  We  have  little  doubt  that  the  editor  would  have 
gladly  secured  a  subject  of  more  portly  dimensions  from  his  pen. 

Dr.  J.  Solis-Cohen's  article  on  the  Air  Passages  embodies  all  the 
recent  advances  in  this  special  department,  and  adds  greatly  to  the  value 
and  interest  of  this  volume.  To  the  surgeon,  the  section  on  tracheotomy 
in  diphtheria,  is  naturally  of  great  interest.  Dr.  Cohen  is  not  an  enthu- 
siastic advocate  of  this  operation.  The  observations  made  some  years 
ago,  on  a  service  of  five  thousand  operations,  showed  him  that  only  one 
case  in  four  recovered.  He  advocates  with  enthusiasm  the  inhalations 
of  the  steam  of  slaking  lime,  also  evolution  of  steam  in  the  immediate 
vicinity  of  the  patient.  We  have  often  thought  that  the  custom  of 
bathing  the  patient  in  a  constant  moist  atmosphere  was  a  debilitating 
treatment,  and  that  hot  moist  sponges,  prevented  from  cooling  too  rapidly 
by  keeping  the  blanket  well  up,  were  an  equally  effectual*  remedy.  His 


534 


Reviews. 


[April 


advice  on  the  management  of  the  canula  is  sound,  and  valuable  to  young 
as  well  as  to  many  old  surgeons. 

Another  interesting  feature  of  this  article  is  the  table  of  laryngectomies, 
which  number  ninety-one.  The  list  of  deaths  is  most  appalling  to  one 
who  casts  his  eye  rapidly  over  the  list,  but  a  more  careful  examination 
shows  that  death  occurred  in  some  cases  long  after  the  operation  ;  one  case 
is  recorded  as  alive  ten  years  later.  On  the  other  hand,  one-third  of  the 
cases  died  within  two  weeks  after  the  operation.  An  interesting  illustra- 
tion of  the  appearance  of  the  parts  after  removal,  and  of  the  apparatus 
used  for  phonation,  is  inserted  in  the  text. 

One  naturally  turns  with  interest  to  an  article  upon  the  Abdomen.  In 
the  present  case  the  author,  Mr.  Henry  Morris,  is  not  only  a  good  writer, 
but  an  operator  of  considerable  experience  in  this  kind  of  surgery,  the 
result  being  a  production  worthy  of  the  occasion.  Although  something 
of  a  pioneer  in  this  new  field,  our  author  does  not  allow  himself  to  be  too 
radical  in  his  views  on  surgical  progress.  While  surgeons  are  hesitating 
as  to  their  duties  in  a  case  of  penetrating  gunshot  wound  of  the  abdomen, 
it  would  be  well  for  them  to  read  what  he  has  to  say  about  such 
injuries  : — 

' '  in  which  it  is  almost  certain  that  more  or  less  sloughing  must  follow  about  the 
edges  of  the  wound,  and  in  which  the  intestines  are  wounded  in  several  points 
which  would  have  to  be  sought  for  at  the  risk  of  dangerous  and  prolonged  dis- 
turbance and  manipulation,  and  some  of  which  in  all  probability  would  be  over- 
looked by  the  eye  of  the  surgeon,  though  the  officious  inquisitiveness  of  his 
fingers  might  cause  them  to  become  the  seat  of  effusion." 

Sound  as  this  criticism  may  be,  we  venture  to  assert,  nevertheless,  that 
the  number  of  surgeons  who  are  prepared  to  place  this  class  of  injuries 
beyond  the  pale  of  abdominal  surgery  is  comparatively  small.  Indis- 
criminate operating  upon  the  kidneys  is  also  condemned,  although,  as  the 
author  says,  "  the  time  has  forever  gone  when  the  words  with  which 
'  dear  old  Lawrence'  (to  quote  from  a  letter  by  a  physician  who  had  been 
his  pupil)  used  to  begin  one  of  his  lectures,  namely  :  '  the  kidney,  gentlemen, 
is  fortunately  beyond  the  reach  of  the  surgeon,'  will  find  an  echo  of 
assent."  After  laying  down  as  a  cardinal  principle  the  rule  of  the  first 
operator  on  the  kidney,  Simon,  that  extirpation  is  only  permissible  when 
a  patient's  life  is  seriously  threatened  by  disease  and  when  all  other  reme- 
dies have  failed,  because  renal  disease  is  more  dangerous  in  persons  with 
only  one  kidney,  he  concludes  with  this  statement : — 

"  It  is  probable  that  future  experience  will  exclude  from  the  category  of  cases 
for  which  nephrectomy  by  any  method  should  be  done,  tubercular  disease  and 
renal  sarcoma  in  children,  as  well  as  cancer  at  any  period  of  life." 

The  author  looks  upon  the  new  operation  of  gastrectomy  as  still  in  the 
stage  of  experiment.  "  As  yet  the  surgical  mind  is  not  settled  either  as 
to  the  condition  for  which  the  operation  should  be  performed,  or  as  to  the 
precise  steps  of  the  operation  ;  or,  indeed,  as  to  the  justifiability,  not  to 
say  advisability,  of  its  performance." 

The  editor  has  seen  fit  to  make  a  number  of  interpolations,  which, 
although  valuable  in  themselves,  are  we  hardly  think  of  sufficient  import- 
ance to  offset  their  marring  effect  upon  an  article  of  such  excellence.  As 
in  most  of  the  English  articles,  there  is  a  poverty  of  illustration,  economy 
evidently  having  been  practised  at  the  expense  of  distant  authors.  We 
notice,  by  the  way,  two  illustrations  of  intestinal  fistula  by  Bourgery, 
incorrectly  credited  to  Teale. 


1885.] 


The  International  Encyclopaedia  of  Surgery. 


535 


The  concluding  article  on  Hernia  is  written  by  Mr.  John  Wood,  whose 
work  has  given  such  an  impetus  to  the  operation  for  radical  cure.  At 
present  the  senior  surgeon  of  King's  College  Hospital,  the  successor  of 
Ferguson  and  the  colleague  of  Lister,  with  a  quarter  of  a  century's  expe- 
rience in  the  treatment  of  hernia,  his  work  can  no  longer  be  considered  as 
that  of  an  experimenter,  and  the  results  which  he  has  carefully  collected 
and  presented  in  this,  chapter  must  be  regarded  as  probably  the  most 
favorable  which  skill  and  experience  can  produce  to-day. 

Mr.  Wood's  operation  was,  indeed,  not  received  favorably  by  the  pro- 
fession, and  many  substitutes  have  been  brought  forward,  but  we  find  that 
he  has  not  changed  it  in  any  essential  detail  from  that  method  which  he 
employed  twenty  years  ago.  In  his  first  hundred  cases  there  were  three 
deaths,  but  since  the  operation  has  reached  its  present  stage  of  perfection 
he  has  operated  two  hundred  times  consecutively  without  a  single  seriously 
bad  symptom.  Rather  more  than  half  have  been  seen  and  heard  from, 
and  of  these  the  percentage  of  cure  has  been  from  seventy  to  seventy-five. 
In  a  table  of  fifty-five  cases  the  oldest  patient  is  forty  years  of  age,  the 
majority  being  young  adults.  Mr.  Wood  describes  an  operation  for  the 
cure  of  omental  hernia,  but  appears  to  have  used  it  in  young  children,  and 
where  such  form  of  surgical  interference  seems  unnecessary,  owing  to  their 
tendency  to  cure  by  truss.  "  In  the  most  common  cases  of  umbilical  her- 
nia, attended  with  corpulence,  a  fatty  condition  of  the  omentum  and 
general  constitutional  debility,  these  circumstances,  as  well  as  the  age  and 
habits  of  the  patient,  preclude  an  attempt  at  a  radical  cure."  It  is,  how- 
ever, in  precisely  this  class  of  cases  that  the  operation  is  most  needed,  for 
the  truss  often  fails  to  retain  the  hernia,  which  eventually  becomes  irredu- 
cible or  strangulated.  It  is  in  fact  these  aggravated  forms  of  the  affection 
in  people  who  have  passed  middle  life  that  have  given  hernia  so  bad  a 
name.  In  many  of  the  cases  operated  upon  it  is  impossible  to  avoid  rec- 
ognition of  the  very  favorable  prognosis  which  they  offer  under  the  use  of 
a  truss.  Once  beyond  the  control  of  this  apparatus,  a  very  large  per- 
centage is  found  to  be  unsuitable  for  operation.  While  under  the  most 
favorable  circumstances  one  case  in  every  four  is  sure  to  be  a  failure,  the 
operation  can  hardly  be  expected  to  become  popular  with  that  class  of 
patients  who  can  afford  to  provide  themselves  with  a  truss. 

Mr.  Wood's  figures  are  of  special  interest,  as  they  present  results  of 
long  standing  and  are  prepared  with  a  care  and  honesty  which  have  not 
always  been  accorded  to  such  statistics. 

We  are  surprised  to  find  that  he  has  so  little  to  say  about  irreducible 
hernia  and  some  of  the  mechanical  modes  of  treating  it.  It  has  been  the 
custom  to  regard  many  of  these  cases  incurable,  and  many  sufferers  from 
Gibbon  down  to  the  present  time  have  thought  and  still  think  themselves 
a  reproach  to  surgery.  A  more  detailed  statement  of  what  has  been  done 
in  the  management  of  this  distressing  malady  would  have  been  a  valuable 
addition  to  the  article. 

The  Encyclopaedia  has  now  so  nearly  approached  completion  that  one 
can  venture  to  make  an  estimate  of  the  position  which  it  will  occupy  in 
surgical  literature.  We  think  few  will  hesitate  to  agree  with  the  opinion 
that  it  quite  realizes  the  favorable  expectations  that  were  formed  of  it. 
French  and  German  writers  have  produced  treatises  Of  greater  erudition, 
but  for  the  special  purpose  for  which  this  work  was  planned  they  will  not 
compare  so  favorably.  J.  C.  W. 


536 


Reviews. 


[April 


Art.  XXVI. —  Topography  of  the  Anatomy  of  the  Brain.  By  J.  C. 
Dalton,  M.D.,  Professor  Emeritus  of  Physiology  in  the  College  of 
Physicians  and  Surgeons,  New  York,  and  President  of  the  College. 
Three  volumes,  4to.    Philadelphia :  Lea  Brothers  &  Co.,  1885. 

Professor  Dalton's  intention  appears  to  have  been  to  present  a  series 
of  views,  which,  with  the  aid  of  brief  descriptions,  should  show  the  topogra- 
phy of  the  brain.  He  gives  in  the  introduction  an  account  of  the  general 
plan  of  convolutions,  and  now  and  then  he  makes  a  digression  from  the 
description  of  a  plate  to  dwell  on  certain  parts ;  but  there  is  no  compre- 
hensive chapter  on  the  anatomy  of  the  brain.  The  evident  explanation 
of  this  course  is  that  the  plates  speak  for  themselves,  and  are  the  pages  of 
a  book  in  which  the  competent  reader  will  see  the  record  of  the  shape, 
size,  and  relations  of  each  and  every  part  of  the  organ. 

The  method  chosen  is  that  of  sections,  which  were  photographed  and 
reproduced  by  the  heliotype  process.  We  will  speak  of  the  plates  first, 
and  it  is  not  easy  to  speak  of  them  too  highly.  The  first  plate,  showing 
the  upper  surface  of  the  brain,  is  worthy  of  all  praise.  The  appearance 
of  convexity  is  excellent.  One  can  follow  a  convolution  as  it  runs  along 
the  surface  and  finally  passes  out  of  sight  as  one  could  on  the  brain  itself. 

In  the  views  of  the  sections  the  distinction  between  the  gray  and  the 
white  matter  is  very  striking,  but  more  remarkable  is  the  difference  be- 
tween the  shades  of  gray  in  the  three  parts  of  the  lenticular  nucleus. 
One  would  hardly  expect  to  see  the  striation  of  the  gray  of  the  convolu- 
tions about  the  calcarine  fissure,  but  there  it  is  beyond  question.  An 
admirable  effect  is  obtained  in  sections  in  which  a  deeper  part  is  seen 
through  an  opening,  as  in  Plate  IV.,  Series  A,  where  the  outer  wall  of 
the  descending  horn  of  the  ventricle  is  cut  through  by  the  section,  and  we 
see  opposite  a  part  of  the  surface  of  the  hippocampus.  Even  in  the  white 
substance  the  course  of  large  bundles  of  fibres,  such  as  the  posterior  expan- 
sions of  the  corpus  callosum,  can  be  made  out  in  spite  of  the  slight  contrast 
they  present. 

Dr.  Dalton's  choice  of  series  of  sections  for  the  demonstration  of  so 
complicated  an  organ  is  a  sign  of  the  progress  this  method  has  made.  The 
advantages  it  possesses  are  absolute  accuracy  and  clearness  of  representa- 
tion. The  chief,  if  not  the  only,  disadvantage  is  the  difficulty  of  under- 
standing it.  It  might  be  logically  presumed  that  the  study  of  series  of 
sections  through  the  three  chief  planes  of  an  organ  or  a  body  would  suf- 
fice to  give  a  perfect  idea  of  the  structure ;  but  we  know  that  something  more 
is  needed  for  most  of  us.  The  student,  who,  without  previous  knowledge 
of  anatomy,  could  learn  it  by  this  method  would  certainly  be  exceptionally 
gifted.  But  we  will  venture  to  say  that  there  are  few  well  versed  in 
anatomy,  who,  when  they  first  saw  sections,  were  not  astonished  at  the 
new  ideas  they  suggested.  They  have  made  much  clear  that  was  obscure 
before.  This  method  is,  no  doubt,  the  best  for  a  work  of  this  kind 
intended  for  the  proficient  rather  than  for  the  learner,  but  we  must  admit 
frankly  that  even  here  some  representations  of  dissections  would  have  been 
welcome.  It  is  true  that  there  are  some  in  the  text,  but  we  should  have 
been  glad  to  see  them  among  the  plates.  The  description  accompanying 
the  plates  is  necessarily  fragmentary,  and  we  regret  that  the  author  did 
not  see  fit  to  extend  his  account  of  the  general  plan  of  the  convolutions  to 
one  of  that  of  the  whole  brain.  In  spite  of  these  shortcomings,  which  we 
surely  have  not  understated,  the  sectional  method  must  be  admitted  to  be 


1885.]    D  Alton  ,  Topography  of  the  Anatomy  of  the  Brain.  537 


admirable.  It  is  particularly  adapted  to  show  the  course  of  curved  struc- 
tures. How  perfectly,  for  instance,  a  series  of  horizontal  sections  through 
the  thorax  shows  the  aorta  arching  over  the  root  of  the  lung  and  gives  its 
relations  at  every  step  of  its  course  !  In  the  same  way  these  sections  show 
beautifully  the  progress  of  the  gyrus  fornicatus,  of  the  fimbriae,  and  of  the 
surcingle  of  the  corpus  striatum.  If  in  some  cases  they  tell  their  story 
only  on  cross-examination,  in  others  they  make  clear  at  once  what  would 
take  many  words  to  explain.  A  student  might  be  somewhat  slow  to  un- 
derstand how  the  convolutions  of  the  insula  and  of  the  operculum  "are 
intercalated  with  each  other  like  the  fingers  of  two  hands  clasped  together," 
but  some  of  the  horizontal  sections  show  the  meaning  at  once.  Vertical 
ones  show  how  part  of  the  cuneus  is  hidden  in  the  calcarine  fissure.  Sec- 
tions of  the  latter  series  show  most  beautifully  the  radiation  of  the  fibres 
of  the  corpus  callosum  towards  the  surface  of  the  brain,  and  the  extra- 
serial  horizontal  section  showing  the  course  of  the  anterior  commissure, 
and  justifying  the  comparison  to  a  Cupid's  bow,  is  most  striking.  We 
must  not  omit  to  mention  that  there  are  many  cross  references  in 
the  text  calling  our  attention  to  the  same  object  shown  in  different 
series.  The  author  observes  that  "a  comparison  of  sections  made  in  dif- 
ferent planes  horizontal,  vertical,  and  longitudinal,  will  often  corroborate 
or  enlarge  the  information  derivable  from  either  of  them  alone."  This 
remark  applies  to  many  points,  but  we  would  mention  particularly  the 
great  ganglia  of  the  base  of  the  brain.  We  think  most  readers  will  rise 
from  the  perusal  of  this  work  with  more  accurate  ideas  of  them. 

The  description  of  the  convolutions  in  the  introduction,  to  which  we 
have  already  alluded,  is  a  model  description  for  clearness  and  brevity. 
We  cannot  imagine  one  more  suitable  in  these  respects  for  a  text-book. 
We  must  be  permitted,  however,  to  dissent  from  the  interpretation  of  the 
central  convolutions.  We  fully  agree  with  the  author  that  the  arched 
arrangement  of  the  convolutions,  which  is  so  evident  in  brains  of  a  simple 
type,  like  that  of  the  fox  for  instance,  is  easily  recognized  in  the  human 
brain  in  spite  of  the  disturbance  due  to  the  fissure  of  Rolando.  We  fail, 
nevertheless,  to  find  any  satisfactory  evidence  in  favor  of  his  theory  that 
the  course  of  the  first  frontal  convolution  is  continued  down  through  the 
anterior  central  convolution,  up  through  the  posterior  one,  and  then  along 
the  superior  parietal,  through  the  occipital  region,  to  the  third  temporal. 
According  to  this  plan  the  third  frontal  convolution  which  is  continued 
along  the  borders  of  both  branches  of  the  fissure  of  Sylvius  is  at  one  part 
of  its  course,  to  wit,  in  the  operculum,  indistinguishable  from  the  first. 
In  other  words,  the  fold  below  the  fissure  of  Rolando  has  to  do  duty  as  a 
part  of  each  of  these  convolutions,  and  the  second  frontal  is  interrupted 
after  all.  We  know  of  no  convincing  argument  in  embryology  or  com- 
parative anatomy  in  favor  of  this  theory.  It  is  much  more  simple,  and  to 
us  more  satisfactory,  to  hold  that  the  first  frontal  is  continued  along  the 
median  fissure  of  the  brain  above  the  fissure  of  Rolando,  and  the  third 
along  the  fissure  of  Sylvius  below  it,  and  to  admit  that  the  second  frontal 
is  divided.  It  would  seem  that  the  author  had  been  led  to  describe  the 
central  convolutions  in  the  manner  needed  for  his  theory.  He  says  that 
they  become  continuous  with  each  other  round  the  lower  extremity  of  the 
fissure  of  Rolando,  and  says  nothing  of  their  equally  constant  union  at  its 
upper  end.  We  wish,  also,  that  he  had  mentioned  the  constant,  though 
small  branch  of  the  parieto- occipital  fissure  on  the  convexity  of  the  brain, 
as  it  is  a  useful  landmark,  and  an  important  feature  of  the  foetal  brain. 


538 


Reviews. 


[April 


Besides  the  introduction,  the  first  volume  contains  ten  plates  represent- 
ing the  surface  of  the  brain  and  longitudinal  sections.  The  second  volume 
contains  fifteen  plates  (of  which  one  is  extra-serial)  of  horizontal  sections, 
and  the  third,  twenty-three  of  transverse  ones.  The  sections  in  the 
second  and  third  volumes  are  in  regular  order  and  at  intervals  of  five 
millimetres.  Each  heliotype  is  accompanied  by  an  outline  bearing  the 
explanations,  than  which  nothing  could  be  clearer. 

In  the  too  few  digressions  which  the  author  allows  himself  from  the 
concise  description  of  the  plates,  he  dwells  particularly  on  the  posterior 
curved  prolongation  of  the  corpus  striatum,  on  the  lenticular  nucleus,  the 
fornix,  and  on  the  parts  that  make  the  descending  horn  of  the  ventricle  so 
difficult.  We  find  repeated  instances  of  Dr.  Dalton's  happiness  of  diction. 
When  we  read  that  the  section  has  passed  "  a  little  to  the  hither  side  of 
the  median  plane,"  we  think  with  a  shudder  in  how  many  words  some 
writers  would  have  hidden  so  simple  an  idea.  Once  in  a  while  we  come 
across  what  appear  to  us  inaccuracies,  which  are  probably  due  to  the  fact 
that  the  author  is  describing  coarse  appearances  rather  than  minute 
structure.  The  statement  that  the  posterior  commissure  is  the  reverted 
border  of  the  tubercula  quadrigemina  is  an  instance. 

We  hope  we  have  said  enough  to  show  that  this  book  amounts  to  a  new 
demonstration  of  the  gross  anatomy  of  the  brain,  and  that  it  is  the  work 
of  a  master.  The  skill  with  which  the  subject  is  treated,  the  number  and 
the  great  beauty  of  the  plates,  the  very  full  index,  the  handsome  paper 
and  printing,  combine  to  make  it  a  remarkable  production.  It  is  sure  to 
add  to  the  well-earned  reputations  of  both  the  author  and  the  publishers. 

T.  D. 


Art.  XXVII  Lectures  on  the  Principles  of  Surgery.    By  W.  H.  Van 

Buren,  M.D.,  LL.D.  (Yalen.),  formerly  Professor  of  the  Principles  and 
Practice  of  Surgery  in  the  Bellevue  Hospital  Medical  College,  etc. 
8vo.  pp.  vii.,  588.    New  York  :  D.  Appleton  &  Co.,  1884. 

This  book  will  be  gladly  welcomed  by  those  who  in  former  years  listened 
to  the  instructions  of  its  author.  It  consists  of  some  of  the  lectures  which 
Dr.  Van  Buren  delivered  at  Bellevue  Hospital  Medical  College,  and  at 
the  University  of  the  City  of  New  York,  with  both  of  which  institutions 
he  was  connected  for  many  years.  They  have  been  edited  by  Dr.  Stim- 
son,  who,  however,  has  not  found  it  necessary  to  make  any  changes  other 
than  a  few  verbal  ones.  Of  Dr.  Van  Buren's  ability  as  a  sound  and  prac- 
tical surgeon  it  is  unnecessary  to  speak.  He  has  left  a  very  definite  per- 
sonal impression  upon  American  surgery,  which  owes  to  him,  among  other 
things,  the  best  method  yet  devised  for  treating  fractures  of  the  femur ; 
and  as  one  turns  over  the  pages  of  this  volume  there  is  found  stamped  upon 
each  leaf  the  evidence  of  sound  surgery,  based  upon  extensive  experience, 
and  combined  with  accurate  scholarship. 

While  in  the  steady  onward  march  of  surgical  science,  no  one  will  look 
to  lectures  dating  back  a  few  years  for  the  latest  dicta  upon  mooted  sub- 
jects, these  utterances  of  Dr.  Van  Buren  will  be  found  to  combine  sound- 
ness of  judgment  and  accuracy  of  observation,  with  such  felicity  of  style 
and  expression,  that  their  perusal  will  more  surely  than  is  often  the  case 


1885,] 


A  New  Method  of  Treating  Chronic  Glaucoma. 


539 


unite  profit  with  pleasure.  Indeed,  we  have  rarely  read  a  surgical  work 
which  is  more  interesting.  John  Bell  has  been  credited  with  having  pro- 
duced the  most  attractive  surgical  work  of  his  day,  but  its  value  was 
marred  by  the  absence  of  an  always  wise  discretion.  These  lectures  may 
fairly  be  regarded  as  rivalling  the  work  of  the  Edinburgh  surgeon  in  in- 
terest, while  the  reader  may  repose  with  perfect  confidence  in  their  wisdom. 
Twenty-seven  in  number,  they  cover  many  of  the  most  important  subjects 
in  surgery,  and  lay  a  broad  and  firm  foundation  of  principles,  upon  which 
details  of  practice  can  be  safely  built.  Although  not  professedly  clinical  lec- 
tures, there  are  interspersed  many  details  of  cases,  which  give  the  charm  of 
narrative  to  their  didactic  instruction,  and  include  many  hints  of  treatment, 
derived  from  a  wide  and  ripe  experience,  which  are  invaluable.  Many  of 
the  chapters  are  worthy  of  special  notice,  but  we  must  content  ourselves 
with  referring  to  the  one  which  treats  of  Shock,  as  a  model  of  thoughtful 
and  thorough  study  of  a  most  important  subject,  than  which  we  are 
acquainted  with  none  better. 

But  as  the  absence  of  novelty  from  the  contents  of  this  book  makes  it 
unnecessary  to  analyze  it  in  detail,  we  have  perhaps  said  enough  to  show 
our  high  estimation  of  it  as  a  work  in  which  the  practitioner  will  most 
pleasantly  refresh  his  knowledge  of  themes  long  since  studied,  and  from 
whose  pages  the  student  may  cull  many  valuable  practical  suggestions.  It 
is  a  fitting  memorial  of  a  most  finished  and  cultured  surgeon,  who  played 
well  his  part,  and  whose  loss  will  be  long  deplored.  The  book  is  well 
printed,  and  by  the  judicious  use  of  italics  it  is  easy  to  pick  out  the  salient 
points  of  interest  scattered  through  it.  S.  A. 


Art.  XXVIII  A  New  Method  of  Treating  Chronic  Glaucoma,  based 

on  Recent  Researches  into  its  Pathology.  By  George  Lindsay 
Johnson,  M.A.,  M.B.,  B.C.  Cantab.,  Clinical  Assistant,  late  House- 
Surgeon  and  Chloroformist,  Royal  Westminster  Ophthalmic  Hospital ; 
Medical  and  Surgical  Registrar,  etc.  8vo.  pp.  48.  London  :  H.  K. 
Lewis,  1884. 

The  object  of  these  pages,  the  author  tells  us,  "is  to  endeavor,  by  a 
process  of  inductive  reasoning,  to  establish  the  truth  of  the  following 
proposition,  and  to  suggest  a  remedy  for  chronic  glaucoma,  which  is  not 
open  to  the  objections  inevitable  to  iridectomy." 

The  first  part  of  his  task  is  a  comparatively  easy  one,  as  most  practical 
ophthalmic  surgeons  have  reached  the  same  conclusion  deductively,  and 
will  give  melancholy  assent  to  the  proposition  "  that  the  ordinary  method 
of  treatment  for  glaucoma  by  iridectomy,  though  highly  successful  in 
acute  forms  of  the  disease,  is  nevertheless  both  uncertain  and  unsatis- 
factory in  the  chronic  condition  of  glaucoma."  Any  new  operation,  with 
a  sound  pathological  basis  or  a  good  empirical  record,  will  meet  with 
little  opposition  from  prejudices  in  favor  of  present  methods  of  treatment. 
A  concise  and  interesting  history  of  glaucoma,  from  early  pre-ophthalmo- 
scopic  times  to  the  present,  is  followed  by  an  excellent  description  of  the 
anatomy  and  physiology  of  the  parts  especially  concerned  in  the  disease, 
particularly  the  lymph  spaces  and  channels,  and  the  course  of  the  fluid 
secreted  by  the  ciliary  processes. 


540 


Reviews. 


[April 


In  part  second,  on  pathology,  the  author,  after  giving  a  resume  of  the 
experiments  and  observations  of  Leber,  Knies,  Weber,  De  Wecker, 
Brailey,  and  Priestley  Smith,  concludes  that— 

' '  I.  The  interior  of  the  eye  is  nourished  by  fluid  elaborated  by  the  uveal 
cells  of  the  ciliary  processes,  and  probably,  to  a  small  extent,  by  the  pigment- 
cells  lining  the  posterior  surface  of  the  iris. 

"  II.  Under  certain  circumstances,  hitherto  not  correctly  determined,  aqueous 
fluid  may  enter  the  anterior  chamber  directly  through  the  trabecular  tissue  at  the 
angle. 

"III.  All  the  fluid  which  does  not  enter  the  posterior  chamber  directly, 
circulates  through  the  vitreous  humor,  and  naturally  through  the  suspensory 
ligament  by  way  of  the  circumlental  space,  enters  the  anterior  chamber,  where 
it  joins  with  the  stream  through  the  posterior  chamber. 

"The  only  possible  means  of  escape  for  this  fluid  is  by  osmosis  through  the 
spaces  of  the  ligamentum  pactinatum  (spaces  of  Fontana)." 

In  the  following  paragraphs  he  gives  his  view  of  the  pathological 
conditions  maintaining  in  acute  and  in  chronic  glaucoma  : — 

"Under  certain  circumstances  the  pressure  in  the  vitreous  becomes  greater 
than  in  the  aqueous  chamber ;  this  causes  the  lens,  suspensory  ligament  and 
ciliary  processes  to  advance  in  such  a  way  that  the  angle  of  the  anterior  chamber 
is  compressed,  and  the  escape  of  lymph  retarded.  Inflammation  and  engorge- 
ment of  the  ciliary  body  and  ciliary  processes  is  the  chief  factor.  The  tension 
rises  rapidly  in  proportion  to  the  intensity  of  the  inflammation,  and  acute 
glaucoma  is  the  result." 

Under  other  circumstances  the  inflammation  of  the  ciliary  region  is  so 
slow  and  insidious  as  to  fail  to  excite 

' '  any  acute  symptom  or  marked  increase  of  tension  ;  but  ultimately  this  in- 
flammation passes  into  a  stage  of  atrophy  and  sclerosis,  and  the  contraction  of 
the  new  tissue  reduces  the  size  of  the  circular  sinus,  and  lymph  channels  around 
the  angle,  and  generally  so  binds  the  iris  by  adhesions  to  the  cornea,  that  the 
outflow  of  lymph  is  unable  to  keep  pace  with  the  inflow,  and  chronic  glaucoma 
is  the  result." 

It  is  claimed  that  this  difference  in  pathology  satisfactorily  explains  the 
difference  in  the  therapeutic  effect  of  iridectomy  in  acute  and  in  chronic 
glaucoma,  that  modern  research  and  experience  have  shown  that  it  is 
useless,  in  the  latter  form  of  the  disease,  to  expect  improvement  from 
operating  upon  the  anterior  chamber,  and  that  the  vitreous  offers  a  much 
better  chance  of  success. 

The  operation  advocated,  which  is  called  "  scleral  paracentesis," 
consists  in  thrusting  a  double-edged,  broad,  thin  knife  through  the 
sclerotic  into  the  vitreous,  towards  the  centre  of  the  globe. 

"The  point  of  the  knife  is  entered  about  4  mm.  behind  the  sclero-corneal 
junction,  and  should  penetrate  to  the  distance  of  about  1  cm.  (nearly  half  an 
inch),  the  flat  side  of  the  instrument  lying  not  quite  parallel,  but  somewhat 
oblique  to  the  long  axis  of  the  eye.  Any  part  of  the  globe  will  do,  but  it  is 
better  to  avoid  transfixing  one  of  the  muscles,  for  obvious  reasons.  The  knife  is 
then  very  slowly  withdrawn,  and  if  the  tension  is  high,  slightly  turned  on  its 
axis  so  as  to  allow  the  lymph  freely  to  escape." 

The  difference  in  principle  between  this  operation  and  some  other 
proceedings  that  have  been  tried,  particularly  Argyll  Robertson's 
trephining  of  the  sclerotic,  does  not  seem  to  us  so  decided  as  it  does  to  the 
author,  but  it  has  the  advantage  over  them  in  simplicity  and  freedom 
from  danger.    The  statistics,  though  not  given  in  detail,  and  not  very 


1885.J 


The  Fifth  Hundred  Ovariotomies  in  Italy. 


541 


definite,  are  encouraging  as  far  as  they  go.  The  author  states  that  he 
has  performed  the  operation  six  times  himself,  has  seen  it  performed  by 
others  in  about  ten  cases,  and  has  taken  notes  of  the  after-results  of  nearly 
as  many  others.  u  In  several  cases  the  sight  has  been  improved  ;  in  all 
except  one  the  tension  was  permanently  lowered,  while  in  none  did  the 
sight  deteriorate  subsequently."  In  two  cases  the  acuteness  of  vision 
was  brought  to  more  than  §§,  and  remained  so  in  one  case  several 
weeks,  and  in  the  other  six  months,  after  the  operation. 

If,  in  more  extended  experience,  such  a  result  as  this  can  be  obtained 
in  two  out  of  say  thirty  cases  of  undoubted  chronic  glaucoma,  the  value 
of  the  operation  will  be  very  great. 

It  is  to  be  regretted  that  the  author  has  allowed  himself  to  give  an  air 
of  originality  and  novelty  to  observations  that  are  not  new ;  and  an 
English  reviewer  has  called  attention  to  the  fact  that,  in  many  instances, 
he  has  not  only  adopted  the  views  of  Priestley  Smith,  but  has  availed 
himself,  almost  verbatim,  of  his  means  of  expressing  them.  And  then, 
too,  the  enthusiastic  reader  who  has  been  led,  by  sundry  references  to  the 
denouement  in  the  earlier  pages,  to  expect  in  operative  therapeutics  a 
discovery  as  purely  inductive  as  that  of  the  Davy  safety-lamp,  will 
experience  a  sense  of  disappointment  when  he  meets,  near  the  close  of  the 
book,  with  the  incidental  statement  that  the  operation  "  was  originally 
suggested  by  Mr.  Cowell  and  Mr.  Rouse."  If  inclined  to  be  skeptical,  he 
may  suspect  that  the  solution  of  the  problem  was  accepted  at  second 
hand,  and  the  inductive  path  to  it  discovered  afterwards. 

These,  however,  are  questions  between  Mr.  Johnson  and  his  confreres, 
and  while  we  may  regret  that  his  book  is  not  more  ingenuous,  we  can 
avail  ourselves  of  its  undoubted  usefulness,  even  if  only  as  a  very  good 
and  very  concise  summary  of  the  subject  of  glaucoma,  whose  literature 
has  assumed  such  .  formidable  proportions  as  to  discourage  most  readers 
from  undertaking  to  master  it. 

A  colored  diagram  of  the  lymphatic  and  vascular  systems  of  the  eye, 
and  several  wood-cuts  are  well  executed.  The  print  is  excellent,  and  the 
little  volume  is  very  neat,  and  in  every  way  creditable  to  the  publisher. 

G.  C.  H. 


Art.  XXIX — Peruzzi  Dott.  Domenico.  Nota  sulla  quinta  centuria 
d'  Ovariotomie  in  Italia,  sidle  operazioni  afjini  e  sulla  Ooforectomia. 

The  Fifth  Hundred  Ovariotomies  in  Italy,  together  with  kindred  Opera- 
tions and  Oophorectomies.  By  Dr.  Domenico  Peruzzi,  of  Lugo. 
Extracted  from  the  Raccoglitore  Medico.  Series  iv.  vol.  xxii.  N.  12- 
13.    8vo.  pp.  27.    Fior,  1884. 

We  have  reviewed  the  former  statistical  records  of  the  author  of  this 
same  series  in  the  numbers  of  this  Journal  for  Jan.  1881,  Oct.  1882,  and 
Jan.  1884,  in  the  last  of  which  will  be  found  a  summary  of  the  preceding 
400  operations.  The  present  record  covers  the  time  from  May  21st,  1883, 
to  June  13th,  1884,  and  its  cases  are  a  fraction  less  successful  than  those 
of  the  last.  There  were  37  saved  out  of  the  first  hundred,  64  of  the  sec- 
ond, 74  of  the  third,  79  of  the  fourth,  and  77  of  the  fifth  and  last.  The 
leading  operator  now  is  Prof.  d'Antona,  of  Naples,  who  has  had  33  of  the 
No.  CLXXVIII  April,  1885.  35 


542 


Reviews. 


[April 


500,  and  saved  25  women.  Dr.  Peruzzi,  who  has  operated  31  times,  has 
no  case  in  the  last  hundred.  In  success,  Prof.  Porro,  of  Milan,  who  has 
recently  assumed  a  leading  position  as  an  ovariotomist,  takes  the  lead, 
having  saved  all  of  his  11  cases  out  of  the  last  hundred,  although,  accord- 
ins;  to  an  established  rule,  one  should  not  be  counted,  having  died  a  month 
after  the  operation  from  pulmonary  gangrene,  attributed  to  embolism  : 
there  were  extensive  parietal  adhesions  broken  up  in  the  operation.  53 
operators  were  engaged  in  the  last  100  operations.  The  causes  of  death 
were  septicaemia  in  8,  septic  peritonitis  in  7,  shock  (colasso)  in  4,  suppu- 
rative pelvi-peritonitis  in  1,  rheumatic  entero-peritonitis  in  1,  intestinal 
occlusion  in  1,  and  carbolic  poisoning  in  1, — 23.  The  double  operations 
were  10,  followed  by  cure  in  7  :  the  simple  ovariotomies  62,  and  those 
complicated  by  adhesions  of  a  grave  character  25.  The  remaining  3  were 
complicated  with  pregnancy,  two  of  which  aborted,  and  the  third  pro- 
gressed to  term.  In  no  operation  was  the  abdomino-vaginal  drainage 
tube  used  ;  in  a  few,  the  abdominal,  and  in  all,  the  treatment  was 
Listerian. 

Partial  ovariotomies  were  performed  in  12  cases,  the  operations  not 
being  completed  because  of  insuperable  adhesions  in  the  pelvis,  to  the 
viscera,  and  the  abdominal  parietes.  In  all  the  cases,  the  portion  of  cyst 
remaining  was  united  by  sutures  with  the  abdominal  wound.  Four  women 
died,  three  of  septicaemia  and  one  of  collapse. 

There  were  27  supra-vaginal  laparo-hysterectomies,  proving  fatal  in 
17  cases.    The  exploratory  operations  were  10,  with  3  resulting  fatally. 

The  Oophorectomies  (Battey's  operation)  of  Italy  now  number  14,  of 
which  6  were  in  the  first  half  of  1884,  5.  of  which  were  by  Prof.  Chiara, 
of  Florence,  who  operated  by  Tait's  method  (removing  the  Fallopian 
tubes)  for  uterine  fibromas,  and  saved  4  cases.  Of  the  14  cases,  3  died. 
The  operations  were  performed  for  hystero-cpilepsy,  hysterical  mania, 
nymphomania,  neuroses  with  ovarian  disease,  and  fibro-myomata. 

R.  P.  H. 


Art.  XXX — Diseases  of  the  Urinary  and  Male  Sexual  Organs.  By 
W.  T.  Belfield,  M.D.,  Author  of  Relations  of  Micro- Organ  isms  to 
Disease  (Cartwright  Lectures,  1883)  ;  Pathologist  to  the  Cook  County 
Hospital  ;  Surgeon  to  the  Genito-Urinary  Department,  Central  Dis- 
pensary, Chicago ;  Physician  to  the  Oakwood  Retreat,  Geneva,  Wis. ; 
Professor  of  Microscopy,  Chicago  College  of  Dental  Surgery.  Wm. 
Wood  &  Co.:  New  York,  October,  1884. 

This  book  is  the  October  issue  of  "  Wood's  Library  of  Standard  Medi- 
cal Authors."  After  a  most  careful  perusal  from  title-page  to  finis  we 
feel  at  a  loss  to  decide  whether  the  good  or  the  bad  preponderates.  The 
work  has  evidently  been  written,  not  because  the  author  had  anything 
specially  new  to  say,  or  that  if  left  to  himself  he  would  ever  have  written 
such  a  book,  but  because  he  had  been  requested  to  do  so  by  the  publishers. 
Now  it  is  not  uncommon  for  most  excellent,  nay,  standard  works,  to  be 
written  under  such  a  stimulus,  but  quite  as  commonly  the  author  only 
does  himself  an  injustice.  Dr.  Belfield  acknowledges  in  his  preface  that 
"  he  has  been  seriously  embarrassed  by  the  brevity  of  the  period  allotted 
for  the  work,  which  has  permitted  no  opportunity  for  a  minute  scrutiny  of 


1885."]        Diseases  of  the  Urinary  and  Male  Sexual  Organ 


543 


pertinent  literature,  for  a  careful  revision  of  the  text,"  etc.  This  latter 
omission  is  most  unfortunately  conspicuous.  For  instance,  on  page  244 
the  author  says  :  "  It  is  a  singular  fact  that  still-born  children,  even  those 
born  at  full  tei-m,  do  not  exhibit  such  (uric  acid)  infarcts."  On  the 
fourth  line  below  this  he  again  says  :  "  In  recent  years  it  has,  however, 
been  demonstrated  in  repeated  instances  that  such  infarcts  may  be  present 
in  the  kidneys  of  infants  which  have  never  breathed,"  thus  denying  what 
he  has  just  positively  asserted.  This  may  seem  a  captious  criticism, 
but  a  reference  to  the  text  shows  that,  from  the  supposed  fact  of  the  ab- 
sence of  these  infarcts  in  children  who  have  never  breathed,  Virchow  has 
regarded  their  presence  as  a  medico-legal  proof  of  the  infants  having  been 
born  alive. 

As  this  work  will  probably  have  a  wide  circulation  among  those  ill 
fitted  to  judge  by  previous  experience  as  to  its  value,  we  feel  reluctantly 
compelled  to  call  attention  to  its  manifest  errors  and  shortcomings.  On 
page  276  the  author  speaks  of  hot  hip-baths  at  "30°  to  33°,"  giving 
nothing  to  indicate  the  scale  ;  but,  of  course,  he  manifestly  means  Centi- 
grade, since  at  30°  F.  the  water  would  be  ice!  On  page  299  he  advises 
the  "  local  effects  of  a  cold"  (the  italics  are  in  all  cases  ours)  "  douche  to 
be  obtained  by  the  use  of  water,  the  temperature  of  which  should  be  at 
first  30°  to  33°,  and  may  be  gradually  decreased,  during  three  or  four 
successive  injections  at  the  same  sitting,  to  25°  or  20°."  Manifestly  the 
Centigrade  scale  must  be  meant  here  ;  yet  how  can  "30°  to  33°"  in  one 
case  be  hot  and  in  another  cold  ?  Knowing  the  peculiarities  of  certain 
medical  readers,  we  cannot  regard  the  careless  omission  of  the  necessary 
C.  or  F.  as  a  slight  error.  In  another  place  he  also  speaks  of  hot  injec- 
tions heated  up  to  "  120°."  We  confess  our  inability  to  ascertain  which 
kind  of  thermometer  he  uses. 

Dr.  Belfield  in  his  preface  also  distinctly  states  that  his  chief  aim 
throughout  the  work  has  been  to  render  clear  the  cause  of  the  morbid 
conditions  rather  than  a  u  recognition  of  morbid  symptoms  only."  We 
feel  compelled  to  state  that  while  we  have  risen  from  the  perusal  of  this 
book  in  the  possession  of  many  new  facts,  we  feel  less  able  to  make  a 
diagnosis  of  the  "  causes"  of  the  various  phenomena  than  when  we  sat 
down.  The  reason  of  this  mental  bewilderment  is  clear.  The  work  is 
written  from  a  peculiarly  German  standpoint,  with  all  the  painstaking 
minuteness  which  so  often  characterizes  Teutonic  work.  Dr.  Belfield  is 
like  an  inexperienced  artist,  who,  having  first  made  a  rude  and  striking 
outline  sketch  of  his  sitter,  easily  recognizable  by  any  tyro  as  an  excellent 
portrait,  is  dissatisfied  with  its  unimportant  inaccuracies  and  crudeness. 
Accordingly,  he  proceeds  "  to  work  it  up,"  and  introduces  every  possible 
shade  and  variety  of  tint,  with  every  conceivable  accessory,  until  the  most 
able,  connoisseur  fails  to  recognize  what  special  object  the  artist  has  been 
endeavoring  to  depict,  although  he  sees  "holes  in  the  lace  collar  or  the 
specks  of  snuff  on  the  doublet." 

This  is  precisely  what  the  writer  has  inadvertently  done.  There  is  an 
immense  fund  of  information  ;  facts  pathological,  physiological,  and  sur- 
gical are  supplied  in  such  profusion  as  to  render  a  thoroughly  complete 
review  impossible,  so  that  no  further  analysis  of  the  work  will  be  at- 
tempted. Many  omissions,  a  considerable  number  of  errors,  and  the 
insistance  upon  some  pet  German  theories  to  the  exclusion  of  facts,  ren- 
dered possible,  we  cannot  but  think,  by  want  of  an  extended  personal 
experience,  mar  the  book. 


544 


Reviews. 


[April 


Considering  the  large  amount  of  knowledge  on  genito-urinary  subjects, 
especially  stone,  gonorrhoea,  etc.,  which  we  owe  to  the  labors  and  writings 
of  French,  English,  and  American  surgeons,  the  almost  total  absence  of 
reference  to  their  labors  is  strangely  conspicuous. 

The  unfortunate  competition  between  various  medical  publishers  is 
flooding  the  market  with  numberless  medical  libraries,  cyclopaedias,  etc., 
by  "  standard  medical  authors,"  which,  instead  of  being  the  outcome  of  a 
ripe  experience,  and  of  years  of  labor  and  writing,  are  thrown  off  in  a  few 
months  by  ambitious  aspirants  for  practice,  who,  if  they  had  waited  for 
time  to  ripen  their  knowledge,  would  in  many  cases  doubtless  produce 
works  of  permanent  value. 

We  believe  Dr.  Belfield  capable  of  work  of  so  much  higher  character 
than  the  present,  that  we  cannot  but  regret  his  having  consented  to  pub- 
lish this  book,  which,  if  pruned  down,  with  theories  checked  by  further 
experience,  and  having  its  errors  eliminated  by  careful  proof-reading, 
would  be  a  useful  work  of  reference,  even  if  not  a  perfect  guide  to  practice. 

C.  B.  N. 


Art.  XXXI — Surgery  of  the  Urinary  Organs.  By  Sir  Henry  Thomp- 
son, F.R.C.S.,  M.B.  Lond.,  Professor  of  Surgery  and  Pathology  to  the 
Royal  College  of  Surgeons.  8vo.,  pp.  147.  Philadelphia :  P.  Blakiston, 
Son  &  Co. 

This  book  consists  of  six  lectures  given  at  the  Royal  College  of  Sur- 
geons last  June.  Parts  of  them  have  been  printed  in  various  journals,  but 
they  now  appear  entire  for  the  first  time.  Lectures  II.  and  III.  deal  with 
the  subject  of  physical  exploration  of  the  bladder  and  the  removal  of 
tumors  therefrom,  but  their  substance  received  full  notice  in  the  preceding 
issue  of  the  American  Journal  of  the  Medical  Sciences.  We  shall, 
therefore,  confine  ourselves  to  the  topics  treated  in  the  other  lectures, 
though  they  deal  with  matters  more  generally  known  to  the  profession  at 
large.  Whatever  Sir  Henry  Thompson  writes  on  the  surgery  of  the  urinary 
organs  is  sure  to  be  worth  reading,  and  it  is  entitled  to  most  careful  con- 
sideration. For,  as  he.  himself  states,  his  experience  has  been  exceptional 
both  in  character  and  extent,  while  the  use  he  has  made  of  it,  and  the 
years  of  study  he  has  bestowed  upon  it,  have  resulted  in  making  him  the 
highest  living  authority  upon  these  topics. 

Lecture  I.  treats  of  strictures  of  the  urethra,  containing  a  review  of  the 
treatment  by  dilatation  alone,  and  a  statement  of  his  own  views  as  to  the 
expediency  of  internal  urethrotomy.  This  operation  Sir  Henry  Thompson 
has  practised  with  increasing  confidence  since  1855.  At  first  it  was  only 
in  the  worst  forms  of  stricture,  those  that  were  very  dense  and  very  re- 
sistant, that  he  resorted  to  internal  division,  and  in  many  recent  cases  he 
yet  adheres  to  simple  dilatation,  but  his  experience  with  internal  urethrot- 
omy has  been  so  favorable  that  he  has  been  practising  it  with  continually 
greater  freedom.  Altogether,  Sir  Henry  Thompson  has  done  the  opera- 
tion on  between  three  and  four  hundred  patients  with  very  satisfactory 
results.  Less  than  three  per  cent,  have  died.  Three  succumbed  to  pyae- 
mia, one  to  embolism,  and  two  to  extravasation  and  exhaustion.  While 
the  lecturer  recommends  a  freer  use  of  internal  urethrotomy  than  formerly, 


1885.]         Thompson,  Surgery  of  the  Urinary  Organs. 


545 


it  must  not  be  thought  that  he  advises  a  resort  to  it  in  every  case.  In 
those  where  the  history  is  recent  he  thinks  that  dilatation  with  elastic 
bougies  is  all  that  is  necessary,  and  by  their  occasional  use  comfort  may 
be  enjoyed  for  many  years,  though  with  advancing  life,  and  the  general 
hardening  of  tissues  which  accompanies  that  advance,  the  stricture  may 
be  expected  to  become  more  troublesome.  When,  however,  a  stricture 
shows  a  tendency  to  contract,  either  early  in  its  history,  or  after  years 
of  successful  stretching  by  bougies,  Sir  Henry  thinks  it  wise  to  recommend 
an  immediate  urethrotomy.  By  making  the  urethra  freely  patent,  he 
thinks  that  very  many  of  those  conditions  which  are  produced  by  the  ob- 
struction, and  complicate  its  treatment  most  seriously,  may  be  prevented. 
To  delay  division  of  a  stricture  which  shows  a  disposition  to  contract,  or 
which  is  intolerant  of  bougies,  can  do  no  good,  and  is  the  fruitful  source  of 
perineal  abscesses,  cystitis,  and  various  organic  changes  in  bladder,  ureters, 
and  kidneys. 

To  do  an  internal  urethrotomy  properly  and  accurately,  the  location  of 
each  stricture  should  be  ascertained  by  the  use  of  bulbous  bougies.  Then, 
with  the  author's  own  instrument,  after  passing  all  the  strictures,  the  knife 
concealed  in  its  bulb  is  projected  to  the  extent  desired,  and  each  stricture 
divided  according  to  its  extent  and  the  amount  of  surrounding  dense  tissue. 
The  bulb  of  the  urethrotome  is  shaped  precisely  like  the  bulbs  on  the 
sounds  by  which  the  strictures  have  been  located,  but  it  cannot  be  made  of 
the  requisite  strength  with  a  diameter  of  less  than  No.  5.  When,  therefore, 
an  instrument  of  that  size  cannot  pass  the  stricture,  an  elastic  catheter  that 
will  pass  is  tied  in,  and  when  sufficient  dilatation  has  been  obtained  in 
this  way,  the  urethrotome  is  used.  For  this  purpose  Sir  Henry  Thompson 
uses  a  small-sized  catheter,  as  causing  little  irritation,  and  allows  it  to 
remain  from  two  to  four  days.  The  bulb  of  the  urethrotome  should  be 
introduced  half  to  three-quarters  of  an  inch  beyond  the  termination  of  the 
stricture,  the  blade  projected  towards  the  floor  of  the  urethra,  and  the 
dense  resisting  tissue  divided  somewhat  as  it  is  done  in  tenotomy.  Imme- 
diately after  division  a  full-sized  sound  is  passed,  and  if  any  obstacle  is 
encountered,  the  urethrotome  is  again  made  use  of,  and  then  a  gum  cath- 
eter is  tied  in  for  at  least  twenty-four  hours. 

As  will  be  seen  it  is  permeable  strictures  that  our  author  thus  divides, 
his  experience  having  shown  him  that  while  any  stricture  may  be  dilated 
to  almost  any  calibre,  by  tying  in  a  succession  of  flexible  gum  catheters, 
it  is  the  tendency  to  narrow  rapidly  after  any  dilatation  which  determines 
him  to  advise  a  urethrotomy.  Like  Mr.  Syme,  Sir  Henry  Thompson  does 
not  believe  in  impermeable  strictures,  stating  that  he  has  only  met  with 
three  that  he  could  not  pass,  but  he  in  general  rejects  Mr.  Syme's  opera- 
tion, for  the  reason  that  a  perineal  section  only  divides  one  stricture  and 
does  not  remedy  the  other  ones  which  so  generally  exist,  resorting  to  the 
buttonhole  proceeding  only  very  rarely,  when  perineal  fistulae  and  abscesses 
complicate  the  case.  Sir  Henry  Thompson  insists  that  all  the  resisting 
tissue  should  be  divided,  or,  as  he  sententiously  formulates  it,  "  if  you  cut 
at  all,  cut  all."  In  a  few  cases  the  relief  is  permanent,  but  in  the  great 
majority  there  is  an  ultimate  return,  which  will  require  a  repetition  of  the 
operation.  In  three  cases  Sir  Henry  Thompson  has  done  the  operation 
for  the  third  time,  and  he  concludes  that  a  free  internal  urethrotomy  is  the 
safest  and  quickest  method  of  treatment,  when  the  easy  use  of  the  bougie 
fails  to  bring  comfort,  and  that  it  is  the  best  means  for  insuring  the  future 
sound  condition  of  the  more  deeply  seated  organs. 


546 


Reviews. 


[April 


We  pass  over  the  next  two  lectures  for  the  reasons  noted  at  the  begin- 
ning of  this  review,  and  direct  attention  to  Lecture  IV.,  which  deals  with 
the  various  forms  and  consequences  of  impaired  vesical  function.  This 
condition,  the  lecturer  thinks,  is  not  sufficiently  attended  to  by  the  pro- 
fession, while  his  experience,  as  a  consultant  leads  him  to  regard  it  as  a 
most  fruitful  cause  of  many  troubles.  The  inability  of  the  bladder  to  com- 
pletely empty  itself  is  by  no  means  rare,  and  the  existence  of  this  condition  is 
never  an  insignificant  matter,  but  always  productive  of  evil,  and  Sir  Henry 
Thompson  urges  upon  the  profession  the  prime  importance  of  recognizing 
this  fact.  He  then  treats  in  some  detail  of  that  abnormal  growth  of  the 
prostate  which  occurs  in  persons  over  fifty,  but  which  his  experience  con- 
vinces him  is  of  greater  rarity  than  is  stated  by  some  writers.  Even 
when  examination  per  rectum  fails  to  reveal  the  existence  of  an  enlarged 
prostate,  experience,  taken  in  connection  with  post-mortem  examination, 
has  abundantly  proven  that  a  quite  small  growth  between  the  two  lobes 
may  very  completely  occlude  the  exit  of  the  bladder,  and  lead  to  retention 
of  its  contents.  But,  unless  the  affection  is  recent,  Sir  Henry  Thompson 
is  entirely  opposed  to  the  internal  cutting  operations  which  have  been  pro- 
posed, because  the  bladder  will  often  be  found  to  have  lost  the  power  to 
expel  its  contents.  Where  the  affection  is  recent  and  the  bladder  has  not 
lost  power,  he  thinks  that  his  own  method  of  reaching  the  bladder,  by  a 
limited  perineal  incision,  and  attacking  the  growth  through  that  incision, 
offers  the  best  prospects  for  a  successful  issue.  But  he  has  not  practised 
the  proceeding.  After  a  few  remarks  upon  the  gravity  of  true  paralysis 
of  the  bladder,  our  author  goes  on  to  treat  of  the  conditions  which  have 
been  generally  known  as  atony.  First  among  these  conditions  he  treats 
of  chronic  inflammation  of  the  coats  of  the  bladder,  induced  by  repeated 
attacks  of  cystitis,  resulting  in  hypertrophy  of  the  walls,  the  patient  being 
subject  both  to  an  inability  to  distend  the  bladder  and  inability  to  com- 
pletely empty  it.  Then  we  have  irritation  of  the  neck  of  the  bladder  and 
congestion  of  the  prostate,  not  hypertrophy,  induced  by  repeated  attacks 
of  gonorrhoea  and  irregular  living,  incautious  mechanical  treatment,  calcu- 
lus, or  retained  fragments  of  one.  Although  the  amount  of  urine  retained 
in  these  cases  may  be  very  small,  the  lecturer  deems  it  of  the  utmost  im- 
portance that  the  organ  should  be  thoroughly  emptied  by  the  use  of  the 
soft  catheter  at  regular  intervals,  if  we  would  avoid  permanent  injury.  Sir 
Henry  then  goes  on  to  point  out  the  importance  of  careful,  gentle  cathe- 
terism  by  soft  instruments,  and  with  many  details  upon  which  we  cannot 
dwell  here.  He  points  out  the  aversion  which  many  persons  have  to  the 
use  of  instruments,  which  aversion  is  shared  by  many  members  of  the 
profession,  an  aversion  born  of  the  rough  and  heroic  treatment  too  often 
adopted  in  former  times,  and  which  he  hopes  may  gradually  disappear 
under  the  prevalence  of  the  gentler,  and,  therefore,  better  methods  which 
have  been  advocated  of  late  years.  This  lecture  is  full  of  interest  and  is 
a  forcible  appeal  for  the  proper  use  of  proper  instruments,  as  the  essential 
treatment  necessary  for  the  relief  of  very  many  bladder  symptoms. 

Lecture  V.  is  devoted  to  a  consideration  of  the  progress  of  operative 
surgery  for  the  relief  of  stone  during  the  present  century,  and  a  notice  of 
the  most  recent  improvements  in  lithotrity.  A  brief,  but  most  interesting 
historical  account  introduces  the  subject,  not  the  least  attractive  portion 
of  which  is  that  in  which  the  lecturer  tells  of  his  relations  with  M.  Civiale, 
to  whom  he  acknowledges  his  obligation,  and  whose  pupil  he  styles  him- 
self.   The  gradual  progress  of  lithotrity  is  detailed  and  the  contributions 


1885.]         Thompson,  Surgery  of  the  Urinary  Organs. 


547 


to  its  perfection  as  an  operative  procedure  are  noted.  In  1878,  the  me- 
thod of  removing  all  calculi  at  one  sitting  was  devised  and  proposed  by 
our  own  countryman,  Dr.  Bigelow,  and  has  been  adopted  by  Sir  Henry 
Thompson,  who  now  speaks  of  it  upon  the  basis  of  an  experience  with 
some  two  hundred  cases.  While  adopting  Dr.  Bigelow's  procedure,  our 
author  has  modified  some  of  its  details.  He  is  particular  to  point  out  that 
from  the  days  of  Heurteloup  the  aim  of  surgeons  has  been  to  get  rid  of  the 
whole  stone  at  once,  but  he  very  fairly  admits  the  great  advance  which 
has  been  made  by  Dr.  Bigelow's  plan  and  his  advocacy  of  it,  though  un- 
willing to  adopt  the  name  "  Litholapaxy"  proposed  by  Professor  Bigelow. 
Sir  Henry  Thompson  insists  that,  ordinarily,  larger  instruments  than  will 
easily  traverse  the  urethra  should  not  be  resorted  to.  No.  15,  English  scale, 
he  has  found  amply  sufficient  in  the  vast  majority  of  cases,  as  wrhen  that 
size  is  readily  admitted  to  the  bladder  it  is  quite  easy  and  safe  to  pass  one 
a  size  or  even  two  sizes  larger  should  it  be  required.  Professor  Thompson 
uses  lithotrites  of  the  ordinary  form.  The  only  modifications  of  the  evac- 
uator  he  mentions  are  a  tap  with  funnel-shaped  opening  to  the  upper  half 
of  the  India-rubber  ball,  by  which  it  can  be  readily  filled,  or  air  accident- 
ally introduced  removed,  and  a  wire  valve  by  which  fragments  which  have 
once  entered  the  receiver  are  prevented  from  re-entering  the  bladder. 
After  the  operation  Sir  Henry  Thompson  keeps  his  patients  in  bed,  watch- 
ing against  the  retention  of  urine,  but  otherwise  avoiding  the  use  of  cathe- 
ters. He  recommends  a  weak  solution  of  nitrate  of  silver,  half  a  grain  to 
four  ounces  of  water,  as  most  efficient  in  subduing  chronic  cystitis. 
Within  a  period  of  a  little  more  than  five  years  he  has  operated  upon  211 
male  adults  for  stone,  but  in  only  15  of  these,  has  he  resorted  to  lithotomy. 
These  15  were  of  course  the  most  unpromising  cases,  and  no  less  than  7 
deaths  occurred  among  them.  In  the  remaining  196  cases  lithotrity  was 
resorted  to,  and  in  all  but  two  the  stone  was  removed  at  one  sitting.  In 
one  case,  from  fear  of  the  long  administration  of  an  anaesthetic,  five  sit- 
tings were  resorted  to,  and  in  one,  where  the  calculus  was  of  oxalate  of 
lime,  and  large,  four  sittings  were  had. 

The  mortality  in  the  whole  series  of  211  cases  was  17,  or  8  per  cent.  ; 
for  the  196  cases  of  lithotrity  10  deaths,  or  5  per  cent.  In  the  latter  part 
of  the  time  during  which  these  cases  presented  themselves  lithotomy  was 
less  frequently  resorted  to,  but  four  instances  of  that  operation  occurring 
in  the  last  1 25. 

The  lecturer  mentions  that  he  has  removed  at  a  single  sitting  lasting- 
seventy  minutes,  a  uric  acid  calculus  weighing  2J  ounces,  the  patient 
being  seventy  years  of  age,  and  making  a  good  recovery.  The  conclusion 
of  Sir  Henry  Thompson  is  that  lithotrity  at  a  single  sitting  bids  fair  to 
supersede  lithotomy  for  the  adult  calculous  patient  in  all  cases  except 
those  in  which  the  stone  is  of  rare  and  exceptional  size. 

Lecture  VI.  and  last  is  perhaps  the  most  valuable  in  the  series.  It 
consists  of  an  analysis  of  the  results  obtained  by  English  surgeons  in  treat- 
ing cases  of  stone,  in  the  past,  when  lithotomy  was  nearly  the  only  resource, 
and  now,  when  it  has  been  in  so  large  measure  superseded  by  lithotrity. 
The  lecturer  points  out  that  whereas  in  the  past  a  patient  rarely  under- 
went more  than  one  operation  for  stone,  being  deterred  by  the  pain  and 
risks  of  the  operation  from  submitting  to  it  save  in  the  last  extremity, 
now  it  is  quite  common  for  one  to  have  stones  crushed  again  and  again t 
as,  both  the  dread  and  risk  of  the  proceeding  having  been  reduced  to  a 
minimum,  it  is  desirable  that  any  concretion,  however  small,  should  be 


548 


.Reviews. 


[April 


at  once  removed  from  the  bladder,  instead  of  waiting  until  the  distress 
can  be  no  longer  borne.  As  a  consequence  of  this  change  it  is  pointed  out 
that  hereafter  an  operation  can  no  longer  be  looked  upon  as  almost  invari- 
ably the  equivalent  of  one  case,  for  it  may  quite  frequently  be  merely  one 
incident,  and  even  an  unimportant  one  in  the  history  of  the  case.  Now, 
as  a  calculus  can  be  removed  by  lithotrity  with  comparatively  little 
risk,  and  that  risk  diminishes  with  the  size  of  the  stone,  an  operation 
is  recommended  and  submitted  to  at  the  earliest  possible  day.  Conse- 
quently a  calculous  patient  may  have  concretions  repeatedly  crushed, 
instead  of  waiting,  as  was  formerly  the  case,  for  the  development  of  one  of 
large  size,  and  its  removal  by  lithotomy.  Hence  Sir  Henry  Thompson 
says — 

"  that  a  computation  of  the  results  of  lithotrity  is  not  possible  by  the  numerical 
record  of  cases  only,  and  by  the  bare  exhibition  of  a  list  of  so-called  'cures,' 
and  deaths;  but  that  the  entire  record  of  the  calculous  patient's  history — its 
commencement,  the  number  of  operations,  the  quantities  of  debris  removed,  and 
the  incidents  of  the  subsequent  history,  so  far  as  they  can  be  obtained — are  essen- 
tial in  order  to  furnish  evidence  in  regard  of  the  treatment  employed,  and  to 
render  the  case  useful  as  a  contribution  to  surgical  experience." 

As  an  aid  to  greater  accuracy  in  recording  cases  Professor  Thompson  re- 
gards all  first  operations,  whether  the  stone  is  large  or  small,  as  an  "  operation 
for  the  stone,"  but  styles  those  deposits  which  form  frequently  afterwards, 
and  which  are  crushed  when  small,  "  concretions,"  and  does  not  include 
their  removal  in  his  list  of  operations.  To  formulate  a  rule  in  these  cases 
is  difficult,  but  the  lecturer  suggests  that  when  after  the  removal  of  the 
primary  "  stone"  it  becomes  necessary  again  to  empty  the  bladder,  all 
formations  of  less  than  a  drachm  in  weight  should  be  recorded  as  "  con- 
cretions" rather  than  as  "  stones."  His  own  cases  occurring  within  the 
past  twenty-five  years  consisting  of  812  operations  upon  716  individuals 
have  been  classified  according  to  this  plan. 

The  lecturer  then  institutes  a  comparison  between  704  cases  collected 
by  Crosse  in  the  period  when  the  knife  always  was  resorted  to ;  304  cases 
of  Keith  and  271  of  Sir  W.  Fergusson,  in  the  era  when  the  practice  was 
divided  between  lithotomy  and  lithotrity,  and  812  of  his  own  cases, 
during  the  time  since  lithotrity  has  become  the  rule.  Of  Crosse's  704 
cases,  occurring  at  the  Norfolk  and  Norwich  Hospitals  35  were  females, 
with  2  deaths ;  343  were  males  below  20  years,  with  27  deaths,  or  8  per 
cent.,  and  326  were  males  above  20  years  with  64  deaths  or  20  per  cent. 
Of  the  whole  number  75  males  were  over  sixty  years  of  age,  among  whom 
the  deaths  were  22,  or  30  per  cent.  About  the  same  averages  obtain  in  a 
series  of  1827  lithotomies  collected  by  Sir  Henry  Thompson  in  1860. 

Of  304  cases  occurring  in  the  practice  of  Dr.  Keith  of  Aberdeen 
between  the  years  1835  and  1868,  or  the  period  termed  by  the  lecturer 
transitional,  4  were  females  and  23  children.  In  the  remaining  277  adult 
males  lithotomy  was  done  on  161,  with  a  mortality  of  38,  or  24  percent.  ; 
lithotrity  upon  116,  with  a  mortality  of  7,  or  6  per  cent.  The  mortality 
in  the  total  number  of  adults  was  45  deaths,  or  15  per  cent.  In  1865 
Sir  William  Fergusson  reported  to  the  College  of  Surgeons  his  experience 
with  271  cases.  Of  these,  52  were  lithotomies  in  children,  with  a  mortal- 
ity of  2,  or  4  per  cent. ;  110  were  lithotomies  in  adults,  followed  by  33 
deaths,  or  30  per  cent.  ;  and  109  were  lithotrities,  with  12  deaths,  a  mor- 
tality of  11  per  cent.  The  total  mortality  in  the  adult  cases  was  20  per 
cent. 


1885.]         Thompson,  Surgery  of  the  Urinary  Organs. 


549 


Next  follows  an  analysis  of  the  lecturer's  own  statistics,  marvellous  in 
their  proportions  and  most  admirable  in  their  results.  He  tells  us  that 
prior  to  1860  he  was  of  the  opinion  that  lithotrity  should  be  more  gener- 
ally employed,  and  as  a  consequence  his  lithotomies  became  less  fre- 
quent with  each  year,  being  gradually  restricted  to  cases  of  large  calculi. 
In  1878  he  began  to  employ  lithotrity  at  a  single  sitting  (Bigelow's 
method)  and  with  growing  confidence  in  its  efficiency,  with  the  conse- 
quence that,  while  he  has  done  196  lithotrities,  he  has  only  resorted  to 
lithotomy  15  times.  In  the  last  125  cases  only  four  have  been  cut,  while 
121  were  cases  of  lithotrity  at  a  single  sitting,  a  proportion  of  30  by  crushing 
to  1  of  cutting.  In  the  211  cases  the  mean  age  of  the  entire  number  was 
upwards  of  sixty  years.  Altogether  Sir  Henry  at  the  time  this  lecture 
was  delivered  had  performed  812  operations  on  716  individuals.  Of 
these,  13  were  adult  females  ;  10  being  operations  by  lithotomy,  with  one 
death,  and  3  by  lithotrity:  15  were  children;  12  being  operated  on  by 
lithotomy,  with  one  death,  and  3  by  lithotrity.  Two  were  operations  for 
the  removal  of  foreign  bodies,  one  of  which  was  supra-pubic.  782  were 
adult  male  cases,  of  wdiich  110,  or  one-seventh,  were  operated  on  by 
lithotomy,  with  39  deaths,  or  35  per  cent. ;  672  were  operated  on  by 
lithotrity,  with  43  deaths,  or  a  mortality  of  less  than  6-|  per  cent.  The 
total  mortality  in  the  782  male  adult  cases  was  82,  or  10^  per  cent.  At- 
tention is  called  to  the  fact  that  among  the  adult  males  595  individuals 
were  upwrards  of  fifty  years  of  age  at  the  time  of  operation.  Of  the  716 
individuals,  61  were  operated  on  twice,  nine  were  operated  f  on  a  third 
time,  three  a  fourth  time,  and  two  as  often  as  five  times.  The  two  who 
were  the  subjects  of  operation  five  times  were  both  living  in  comfort  at 
the  time  of  the  lecture,  their  histories  reaching  over  from  twelve  to  fifteen 
years.  Certainly  the  position  of  lithotrity  would  seem  to  be  established 
by  these  figures,  and  we  can  hardly  wonder  that  our  author  prints  them 
in  small  capitals. 

Referring  to  the  fact  that  the  reputation  of  an  operator  is  likely  to  at- 
tract to  him  many  desperate  cases,  Sir  Henry  Thompson  tells  us  that  he 
has  declined  to  operate  in  but  six  such  cases.  His  last  125  cases  furnish 
the  remarkably  low  mortality  of  less  than  5  per  cent.  In  addition  to  the 
specimens  exhibited,  the  lecturer  claims  to  have  substantiated  his  statistics 
by  the  clinical  notes  of  each  case,  the  name  of  the  patient,  together  with 
that  of  the  attending  medical  man  with  whom  the  case  was  seen  in  con- 
sultation, and  with  quite  pardonable  pride  he  speaks  of  it  as  the  "faithful 
record  of  one  man's  practice  during  five-and-twenty  years,  as  complete 
and  as  elaborately  reported  as  it  has  been  possible  to  make  it." 

The  experience  of  Sir  Henry  Thompson  has  confirmed  the  opinion  he 
long  since  expressed  that  stone  is  more  prevalent  during  the  latter  third 
of  life  than  at  any  other  period,  and  he  believes  that  the  presence  of  a 
small  acid  stone  is  more  common  in  patients  between  fifty-five  and 
seventy-five  years  of  age  than  it  was  formerly  believed  to  be.  He  thinks 
that  many  men  carry  a  small  stone  in  the  bladder  for  three  or  four  years 
with  little  inconvenience,  beyond  slightly  increased  frequency  of  micturi- 
tion, occasional  uneasiness,  and  a  trace  of  blood  after  unusual  exercise. 
These  slight  signs  he  considers  as  highly  significant,  and  holds  that  by 
paying  attention  to  them,  he  has  often  been  led  to  detect  a  calculus,  and 
remove  it,  at  a  time  when  the  operation  required  was  much  less  serious 
than  the  one  which  would  be  necessary  if  the  stone  was  allowed  to  go  on 
and  develop  into  a  calculus  of  larger  size.    The  early  detection  of  a  stone 


550 


Reviews. 


[April 


is  also  of  the  highest  importance,  by  enabling  the  surgeon  to  pay  that  at- 
tention to  the  habits  and  regimen  of  his  patient  which  will  help  to  arrest 
the  tendency  to  such  formations. 

In  concluding  the  lecture  the  question  of  the  method  of  operation  which 
shall  be  resorted  to  in  a  given  case  is  considered.  This  must  be  princi- 
pally decided  by  the  size  of  the  stone  and  the  calibre  of  the  natural  pas- 
sage to  the  bladder.  For  children,  lithotomy  still  offers  the  best  prospect 
of  success,  but  in  adults,  lithotrity  should  almost  always  have  the  prefer- 
ence. Our  author  has  successfully  crushed  a  hard  uric  acid  calculus 
weighing  nearly  three  ounces  in  a  man  of  seventy,  and  this  would  seem 
to  be  a  fair  maximum  limit  in  which  lithotrity  can  be  relied  on.  For 
larger  stones  Sir  Henry  Thompson  is  disposed,  from  the  unsatisfactory 
results  of  lithotomy  in  these  cases,  to  look  favorably  upon  the  supra-pubic 
operation  as  modified  by  Professor  Petersen,  of  Kiel,  who  distends  the 
bladder  with  a  solution  of  boracic  acid,  and  then  distends  the  rectum  by  a 
pear-shaped  India-rubber  bag  inserted  into  it.  By  this  measure  the 
bladder  is  maintained  above  the  pubis,  and  can  be  safely  reached.  This 
method  has  been  resorted  to  by  Petersen,  by  Guyon  and  Perrier  of  Paris, 
and  by  Dittel  of  Vienna.  But  while  our  author  announces  his  intention 
of  resorting  to  this  method  should  a  case  present  itself,  and  in  fact  did 
perform  the  operation  and  remove  a  calculus  of  cystine  weighing  nearly 
three  ounces,  a  week  after  this  lecture  was  delivered,  he  thinks  that  the 
crushing  operation  is  abundantly  competent  to  deal  with  many  such  cases 
as  are  now  made  the  subject  of  the  high  operation. 

We  have  now  followed  our  author  in  some  detail  to  the  conclusion  of 
these  lectures.  This  we  have  felt  warranted  in  doing  from  the  importance 
of  the  subjects  with  which  they  treat,  from  the  high  authority  of  the 
lecturer,  an  authority  based  not  only  upon  ability,  but  upon  his  unparal- 
leled experience,  and  from  the  admirably  clear  and  forcible  way  in  which 
Sir  Henry  Thompson  presents  his  theme.  The  book  well  sustains  the 
reputation  of  its  author,  and  should  be  read  and  studied  by  every  one  who 
desires  sound  instruction  upon  the  subject  of  the  surgery  of  the  Urinary 
Organs.  S.  A. 


Art.  XXXII. —  The  Ophthalmoscope  and  Lues.    By  Ole  B.  Bull, 
M.D.,  8vo.  pp.  117.    Christiana:  P.  T.  Mailing,  1884. 

The  object  of  this  work  is  the  discussion  of  the  pathological  changes 
resulting  from  syphilis  which  occur  in  the  fundus  of  the  eye,  and  are  re- 
vealed by  the  ophthalmoscope. 

The  first  chapter  consists  of  some  interesting  and  quite  elaborate  "his- 
torical notes"  which  show  that  the  frequent  dependence  of  affections  of  the 
sight  upon  syphilis  was  recognized  very  early  in  the  history  of  the  disease, 
and  "  that  syphilitic  eye  diseases  made  their  appearance  in  the  loth  and 
16th  centuries  in  much  the  same  manner  as  now,  affecting  both  the  mem- 
branes of  the  globe  and  the  percipient  organs  of  the  eye."  In  the  latter 
part  of  the  18th  century  the  knowledge  of  these  diseases  was  as  correct 
as  it  could  possibly  become  without  the  ophthalmoscope,  even  the  heredi- 
tary form  being  recognized.  The  ophthalmoscope  has  shown  that  many 
affections  formerly  attributed  to  the  optic  nerve  and  brain  are  dependent 
upon  lesions  of  the  choroid  and  retina. 


1885.] 


Bull,  The  Ophthalmoscope  and  Lues. 


551 


The  author  maintains  that  more  frequent  ophthalmoscopic  examinations 
would  show  that  it  is  a  mistake  to  suppose  that  syphilitic  affections  of  the 
fundus  oculi  are  more  rare  than  those  of  the  iris,  as  they  are  often  accom- 
panied by  little  or  no  functional  disturbance.  This  is  particularly  the 
case  with  hyperaemia  of  the  optic  disk,  which,  in  a  majority  of  cases, 
causes  no  decided  diminution  of  vision,  and  even  in  the  highest  degree 
("choked  disk")  it  is  well  known  that  the  patient  may  make  no  com- 
plaint of  his  sight. 

He  thinks  that  this  symptom,  which  frequently  appears  at  an  early 
period  of  the  disease,  may  sometimes  be  significant  as  a  means  of  diag- 
nosis, and  says  : — 

"  The  period  of  the  disease  at  which  hyperaemia  most  frequently  occurs  is  the 
later  secondary.  I  have  never  found  it  unless  complicated  with  cerebral  disease, 
later  than  two  years  after  the  infection.  As  a  rule,  it  appears  at  that  period 
when  roseola,  tubeixuila  mucosa,  and  the  affections  of  the  mucous  membrane  of 
the  throat  and  mouth  begin  to  disappear.  In  some  individual  cases  I  have  found 
incipient  hyperaemia  to  be  the  first  symptom  of  the  constitutional  disease.  Its 
appearance  just  at  that  period  when  the  patient  is  usually  discharged  may  prob- 
ably account  for  the  frequency  of*  this  fact  having  hitherto  eluded  notice,  and  this 
reason  may  especially  apply  to  countries  where,  in  the  treatment  of  syphilis,  mer- 
cury is  considered  indispensable,  such  being  the  case  in  most  countries  except 
Norway,  and  where,  consequently,  the  secondary  symptoms  will  be  of  shorter 
duration." 

It  is  well  known  that  "  hyperaemia  of  the  optic  disk"  is  one  of  the  most 
indefinite  and  unreliable  of  symptoms,  and  that  a  decided  "  personal  equa- 
tion" must  be  allowed  for  the  judgment  and  bias  of  the  observer.  The 
appearance  of  the  disk  not  only  varies  greatly  with  the  pigmentation  and 
the  general  vascular  activity  of  different  individuals,  but  even  in  the  same 
person  there  is  a  wide  range  of  variation  within  the  limits  of  health. 
Perhaps  some  poetic  license  must  be  conceded  to  a  recent  writer  who 
asserts  that  the  color  of  the  optic  disk  varies  almost  as  much  as  the  chang- 
ing hue  of  a  maiden's  cheek,  but  the  fact  remains  that  this  symptom  is 
regarded  with  most  suspicion  by  those  who  have  had  most  experience  in 
the  use  of  the  ophthalmoscope.  The  author  has  not  ignored  this  fact, 
and  "  in  order  to  obtain  a  tolerably  accurate  estimate"  has  divided  his 
cases  into  three  classes  :  1st.  Those  in  which  no  hyperaemia  was  visible  ;  2d. 
Those  which  were  doubtful ;  and  3d.  Those  in  which  hyperaemia  was  un- 
doubtedly present.  Of  four  hundred  syphilitic  patients  who  were  fre- 
quently examined,  and  whose  cases  were  accurately  noted,  he  found 
"  indisputable  hyperaemia"  in  20  per  cent.  Cases  of  retinitis  and  decided 
neuritis  are  not  included,  but  the  term  hyperaemia  is  applied  to  those 
"  extreme  degrees"  usually  designated  as  choked  disk,  peripapillar  oedema, 
etc.  ;  and  here  we  find  ourselves  upon  disputed  territory. 

Concerning  the  primary  cause  of  hyperaemia,  the  author  concludes 
"  that  the  limitation  of  the  affection  to  the  optic  nerves  and  the  surround- 
ing parts  of  the  retina  points  to  the  presence  of  some  intracranial  cause." 
He  briefly  discusses  the  three  principal  theories  that  have  been  advanced 
to  explain  the  connection  between  this  condition  of  the  optic  nerve  and 
intracranial  disease,  viz.  obstruction  to  the  venous  circulation  by  com- 
pression of  the  cavernous  sinus  ;  accumulation  of  cerebro-spinal  fluid  in 
the  perineural  spaces ;  and  disturbance  of  the  circulation  due  to  the  influ- 
ence of  the  vaso-motor  nerves ;  and  gives  the  preference  to  the  last. 

In  a  large  proportion  of  the  cases  other  symptoms  indicating  an  affection 
of  the  nervous  system,  such  as  headache,  dizziness,  etc.,  were  noted. 


552 


Reviews. 


[April 


In  the  chapter  on  "  affections  of  the  optic  nerve  in  the  later  stages  of 
syphilis ,"  while  it  is  admitted  that  it  may  sometimes  be  impossible,  by 
the  ophthalmoscope  alone,  to  distinguish  between  a  real  inflammation  and 
a  passive  hyperemia,  the  so-called  "choked  disk"  is  still  considered  to  be 
a  condition  of  passive  hyperemia,  differing  from  slighter  cases  only  in 
degree.  It  has  a  place,  however,  in  this  chapter  because  it  is  usually  a 
symptom  of  some  intracranial  disease  of  a  later  period  and  a  graver  char- 
acter, generally  a  cerebral  tumor. 

The  author  thinks  that  too  free  a  use  is  generally  made  of  the  term 
neuritis,  and  that  "many,  if  not  most,  of  the  cases  recorded  as  neuritis 
syphilitica  ought  to  be  considered  as  cases  of  hyperemia  of  the  optic  disk 
only;"  and  that  relatively  few  cases  of  real  neuritis  are  reported  is  due  to 
the  fact  that  it  belongs  to  a  late  period  of  the  disease,  when  all  signs  of 
infection  have  disappeared,  and  its  specific  character  escapes  detection. 
Its  appearance  within  two  years  after  infection  is  considered  rare. 

Atrophy  of  the  optic  nerve,  both  of  a  primary  and  of  a  secondary  form, 
is  said  to  occur  as  a  result  of  syphilis.  The  latter  form  follows  retino- 
choroiditis,  neuritis,  or  hyperemia  of  the  disk,  and  is  not  generally  con- 
sidered very  rare.  In  establishing  the  existence  of  a  syphilitic  primary 
atrophy  we  meet  not  only  with  the  difficulty  of  connecting  the  condition 
of  the  nerve  with  a  specific  cause,  but  with  the  usually  greater  difficulty 
of  determining  that  it  is  not  the  sequela  of  previous  inflammatory  dis- 
ease. This  latter  can  only  be  done  with  certainty  by  observing  the  patient 
from  the  very  commencement  of  the  attack,  the  opportunity  to  do  which 
but  rarely  occurs.  On  this  account,  one  of  the  four  cases  reported  by  the 
author  seems  to  us  of  special  interest,  as  the  patient  was  under  his  obser- 
vation for  three  years,  and  the  development  of  the  atrophy  was  carefully 
watched  from  the  beginning.  Ophthalmoscopical  examinations  were  fre- 
quently made  before  there  was  any  complaint  of  vision,  and  the  eyes  were 
found  normal.  Subsequently  ophthalmoplegia  and  paralysis  of  the  facial 
and  of  the  arm  and  leg  appeared,  and  were  soon  followed  by  amaurosis  of 
the  right  eye  and  hemianopia  of  the  left.  The  ophthalmoscope  at  this  time 
showed  only  some  diminution  of  the  arteries,  and  atrophy  of  the  disk  was 
noted  later.  A  post-mortem  examination  revealed  "  atrophy  of  the  corpus 
striatum,  nucleus  lentiformis,  and  the  anterior  part  of  thalamus  up  to  fossa 
Sylvii  on  the  left  side." 

More  than  half  of  the  work  is  included  in  the  last  chapter  on  "  affections 
of  the  choroid  and  retina."  The  author  maintains  that  retinitis  and  cho- 
roiditis should  not  be  considered  as  distinct  diseases,  but  that  they  are 
dependent  on  the  same  pathological  process,  which  originates  as  a  rule  in 
the  retina.  Its  origin  in  the  retina  he  attempts  to  prove  by  an  elaborate 
discussion  of  scotomata,  phosphhies,  and  other  symptoms ;  but  we  are  not 
sure  that  he  succeeds  in  establishing  his  view,  which  is  opposed  to  the  one 
more  generally  accepted.  AVhether  the  retina  or  the  choroid  is  first  affected 
seems  to  him  a  question  more  important  than  it  is*  usually  considered. 
"Is  the  disease  of  retinal  origin?  then  this  proves  to  us  that  the  nervous 
system  is  often  severely  affected  in  an  early  period  of  syphilis;  and  the 
occasional  complication  of  mental  diseases  with  retino-choroiditis  would 
then  be  much  better  apprehended."  He  admits  that  no  form  of  the  dis- 
ease is  so  distinctive  that  the  diagnosis  of  syphilis  can  be  established  from 
the  eye  affection  alone. 

This  pamphlet  is  evidently  the  result  of  much  careful,  intelligent,  and 
honest  work,  and  is  a  valuable  addition  to  ophthalmological  literature. 

G.  C.  H. 


1885.] 


Hamilton,  Fractures  and  Dislocations. 


553 


Art.  XXXIII  A  Practical  Treatise  on  Fractures  and  Dislocations. 

By  Frank  Hastings  Hamilton,  M.D.,  LL.D.,  late  Professor  of  Sur- 
gery in  Bellevue  Hospital  Medical  College,  New  York.  8vo.,  pp.  xxxi., 
1005.    Seventh  American  edition.    Henry  C.  Lea's  Son  &  Co.,  1884. 

By  continued  careful  revisions  and  additions,  the  work  of  Dr.  Hamilton 
still  maintains  its  high  place  among  authoritative  treatises.  In  the  present 
edition  there  is  abundant  evidence  of  the  conscientious  care  taken  by  its 
author  to  make  it  fairly  representative  of  the  present  state  of  our  knowl- 
edge concerning  fractures  and  dislocations.  Recent  contributions  to  the 
subject  have  been  scrupulously  examined,  critically,  and  with  much  fair- 
ness. As  a  consequence,  the  opinions  expressed  in  former  editions  have 
in  some  cases  undergone  modification,  and  it  is  impossible  to  avoid  the 
conviction  produced  by  an  inspection  of  the  volume,  that  we  have  in  it  the 
matured  judgment  of  one  who  by  extended  personal  observation,  and  by 
honest  consideration  of  the  experience  of  others,  is  well  entitled  to  occupy 
a  judicial  position. 

Dr.  Hamilton  apologizes  in  his  preface  for  the  rather  low  estimate  he 
places  upon  some  recent  experiments  upon  the  cadaver,  undertaken  with 
a  view  of  explaining  the  rationale  of  dislocations  and  fractures  in  the 
neighborhood  of  the  joints.  He  points  out  the  fact  that  the  absence  of 
muscular  rigidity,  which  always  exercises  a  most  important  influence  in 
the  production  of  such  injuries  in  the  living,  must  do  much  to  invalidate 
experiments  upon  the  dead.  We  hardly  think  the  apology  is  required,  as 
mos^  practical  surgeons  who  are  observant  will  be  quite  ready  to  agree 
with  Professor  Hamilton,  that  while  most  of  these  experiments  furnish 
valuable  information  that  it  would  be  unwise  ,to  reject,  the  results  thus 
obtained  cannot  be  accepted  as  illustrating  precisely  what  occurs  in  trau- 
matisms inflicted  upon  the  living  body.  There  is  another  curious  fact 
which  has  a  bearing  upon  this  subject,  and  which  goes  to  strengthen  the 
position  of  Dr.  Hamilton  ;  we  refer  to  the  truth  established  by  Casper  and 
other  observers,  that  much  greater  force  is  required  to  fracture  the  bones 
of  a  dead  body  than  is  necessary  when  the  body  is  living.  This  fact  is 
not  so  generally  recognized  as  it  should  be>  while  it  has  an  important 
bearing  upon  the  subject  in  hand,  and  is  of  especial  importance  in  some 
medico-legal  investigations. 

In  view  of  the  monograph  published  by  Dr.  Hamilton  three  years  ago, 
the  chapter  upon  Fractures  of  the  Patella  will  be  read  with  especial  in- 
terest. It  is  based  upon  the  same  statistical  inquiries  as  the  monograph, 
and  is  both  full  and  exact.  Dr.  Hamilton  is  convinced  that  the  fibrous 
union  which  so  generally  follows  this  accident  is  a  very  good  result  if  the 
ligamentous  band  is  not  excessive  in  length.  He,  therefore,  does  not  look 
with  favor  upon  some  of  the  severe  forms  of  apparatus  which  have  been 
devised  with  the  hope  of  securing  bony  union.  Nor  does  he  admit  that 
bony  union  is  more  apt  to  follow  the  use  of  hooks  and  other  special  forms 
of  dressing,  than  is  the  case  where  his  own,  or  some  other  simple  appli- 
ance, is  relied  upon.  We  are  emphatically  of  the  opinion  that  Dr.  Ham- 
ilton is  right,  and  that  the  effort  to  revive  the  use  of  Malgaigne's  hooks, 
while  fraught  with  a  certain  percentage  of  great  danger,  is  uncalled  for 
by  the  necessities  of  the  injury.  Dr  Hamilton  applies  a  moulded  splint  of 
shellac  cloth  to  the  back  of  the  limb,  and  secures  the  fragments  of  the 
patella  in  apposition  by  circular  turns  of  a  bandage,  without  reverses. 


554 


Reviews. 


[April 


The  effect  of  slipping  is  overcome  by  stitching  the  turns  of  the  bandage 
immediately  in  contact  with  the  patella  to  the  splint.  Dr..  Hamilton  also 
elevates  the  foot.  By  this  simple  dressing  it  is  claimed  that  most  admi- 
rable results  are  obtained,  and  our  author  no  longer  advocates  the  inclined 
plane  recommended  in  former  editions,  unless  in  exceptional  cases.  Par- 
ticular attention  is  directed  to  the  importance  of  guarding  against  refrac- 
ture,  and  the  position  is  held  that  we  had  better  leave  anchylosis  to  time 
and  gentle  methods,  rather  than  resort  to  violence  to  break  up  adhesions. 

It  is  unnecessary  to  speak  in  detail  of  the  characteristics  and  excel- 
lences of  a  book  so  well  and  favorably  known  to  the  profession  as  this  one 
is.  It  has  grown  in  size,  and  the  number  of  its  illustrations  is  increased, 
but  with  advancing  years  it  is  no  less  an  authority  than  it  has  ever  been. 
There  remains  nothing  for  us  to  say  but  to  reiterate  that  opinion  of  the 
value  of  Dr.  Hamilton's  great  and  monumental  work  which  we  have  so 
often  expressed.  To  the  critic  belongs  a  grateful  task  when  such  a  work 
finds  its  way  to  his  table,  and  pleasant  as  are  the  relations  between  the 
author  and  the  reader  of  a  good  book,  they  are  rendered  closer  when  the 
reader  ventures  upon  friendly  words  of  criticism.  New  editions  of  Dr. 
Hamilton's  work  will  be  called  for,  and  so  long  as  the  same  painstaking 
care  is  exercised  in  their  preparation,  the  book  is  destined  to  maintain  the 
position  it  has  rightfully  earned.  S.  A. 


Art.  XXXIV  Injuries  and  Diseases  of  the  Jaws  :  the  Jacksonian  Prize 

Essay  of  the  Royal  College  of  Surgeons  of  England,  1867.  By  Chris- 
topher Heath  F.R.C.S.,  Holme  Professor  of  Clinical  Surgery  in 
University  College,  London,  etc.  Third  edition.  8vo.  pp.  xii.,  480. 
Philadelphia:  P.  Blakiston,  Son  &  Co.,  1884. 

This  book  is  one  which  calls  for  notice  rather  than  criticism.  Coming 
from  whom  it  does,  one  would  hardly  expect  it  to  be  open  to  objection, 
and  the  author  having  had  the  benefit  of  nearly  twenty  years'  experience 
to  complete  its  merits,  since  first  it  secured  the  approval  of  the  awarders 
of  the  prize  mentioned  in  the  title,  it  would  be  strange  if  it  should  disap- 
point any  reader.  It  is,  we  may  say,  just  what  it  might  be  expected  to 
be  under  the  circumstances  :  a  most  valuable  essay  on  the  subject  of  sur- 
gical diseases  and  injuries  of  the  jaws  and  adjacent  parts.  It  is  not  a 
text-book,  but  a  book  for  the  practising  surgeon,  filled  with  interesting 
accounts  of  cases  and  instructive  details.  Its  value  is  much  enhanced 
by  the  many  illustrations  which  it  contains.  Some  of  these  are  from  the 
works  of  other  surgeons,  some  are  original.  It  is  noticeable,  in  this  day  of 
microscopical  studies,  that  there  is  not  a  single  illustration  of  the  minute 
structure  of  any  of  the  tumors  referred  to.  This,  from  our  point  of  view, 
is  no  great  disadvantage,  and  suggests  the  thought  that  training  in  the 
minutiae  of  microscopical  technique  may  be  a  poor  substitute  for  the  habits 
of  careful  observation  and  reflection  upon  gross  appearances  which  were 
used  with  such  admirable  results  by  our  forefathers.  Laboratory  work 
is  of  the  greatest  value  to  the  science  of  medicine,  but  its  usefulness 
depends  upon  its  occupying  its  true  place  as  a  handmaid,  and  not  being- 
thrust  into  that  of  an  independent  actor.  C.  W.  D. 


1885.] 


Gould,  Elements  of  Surgical  Diagnosis. 


555 


Art.  XXXV  Medical  Diagnosis,  a  Manual  of  Clinical  Methods.  By 

J.  Graham  Brown,  M.D.,  Fellow  of  the  Royal  College  of  Physicians, 
Edinburgh.  Second  edition,  illustrated,  pp.  285.  New  York  and 
London  :  Birmingham  &  Company,  1884. 

Dr.  Brown's  Manual  deserved  a  better  fate.  The  contrast  is  painful 
between  this  dingy,  badly  printed  volume,  and  the  bright,  clean,  red- 
covered  Edinboro'  edition,  and  yet  the  price  of  the  American  reprint  is 
much  the  same,  if  not  a  little  higher.  If  the  publishers  give  the  author 
the  doubtful  pleasure  of  seeing  his  work  in  this  dress,  we  would  suggest 
that  a  soothing  douceur  accompany  it.  We  happen  to  know  that  the 
English  editor  of  Ziegler's  Pathology  only  recovered  from  the  shock 
which  the  meretricious  aspect  of  Messrs.  Wood  &  Co.'s  edition  gave  him, 
upon  the  receipt  of  a  compensating  honorarium. 

From  a  practical  knowledge  of  it,  we  can  commend  this  work  to  teachers 
and  students  as  a  most  trustworthy  manual  of  clinical  methods.    W.  O. 


Art. XXXVI  Elementsof  Surgical  Diagnosis.  By  A.Pearce  Gould, 

F.R.C.S.  Eng.;  Assistant  Surgeon  to  the  Middlesex  Hospital,  London; 
Surgeon  to  the  London  Temperance  Hospital,  and  to  the  Royal  Hospi- 
tal for  Diseases  of  the  Chest.  24mo.,  pp.  viii.  584.  Philadelphia : 
Henry  C.  Lea's  Son  &  Co.,  1884. 

This  convenient  and  handy  volume  is  constructed  according  to  sound 
rules,  and  would  seem  suited  to  satisfy  the  demands  of  those  who  value 
works  especially  devoted  to  diagnosis.  Mr.  Gould  very  properly  insists 
upon  the  importance  of  looking  beyond  any  mere  pathognomonic  signs 
to  the  principles  of  surgery  underlying  and  causing  such  signs.  He 
is  particular  in  laying  down  categorically  the  mental  process  by  which 
each  individual  case  should  be  approached  when  there  is  any  obscurity  in 
it.  It  is  impossible  to  overestimate  the  importance  of  such  a  regular  and 
orderly  way  of  proceeding,  and  as  Mr.  Gould  points  out,  when  such  a  me- 
thod is  pursued,  and  is  combined  with  a  careful  and  minute  observation  of 
the  individual,  the  risk  of  serious  blunder  is  very  small.  So  convinced  is  he 
of  the  essential  importance  of  viewing  §ach  case  by  itself,  that  he  has  dis- 
carded the  plan  of  printing  parallel  columns  containing  the  symptoms  of 
affections  which  may  readily  be  mistaken  for  each  other.  We  recognize 
the  weight  of  Mr.  Gould's  reasons,  and  admit  their  importance  in  construct- 
ing a  systematic  treatise  intended  to  aid  men  in  becoming  accurate  diag- 
nosticians, yet  we  are  inclined  to  think  he  errs  in  excluding  such  tables, 
on  account  of  their  convenience,  and  the  facility  with  which  they  can  be 
referred  to.  For  while  students  and  some  older  men  may  read  a  work 
upon  diagnosis  through,  the  majority  of  practitioners  will  turn  to  it  for  aid 
in  solving  an  obscure  problem,  and  in  such  a  case  the  presence  of  compara- 
tive tables  is  very  convenient.  That  our  meaning  may  be  better  under- 
stood we  will  cite  an  instance.  We  happen  to  have  under  our  care  a  child 
with  osseous  disease,  which  one  competent  authority  pronounces  to  be 


556 


Reviews. 


[April 


owing  to  inherited  syphilis,  and  another,  equally  good,  regards  as  the  re- 
sult of  struma.  In  the  absence  of  other  than  a  presumable  family  history 
the  diagnosis  is  not  easy,  and  we  naturally  turned  over  the  pages  of  this 
little  book  to  enlighten  our  darkness,  and  should  have  been  glad  to  find 
differential  tables  of  symptoms  to  help  us  to  a  conclusion,  but  we  have  had 
to  go  over  much  ground,  instead  of  finding  comparisons  displayed  on  a 
single  page. 

We  have  said  this  much,  not  by  way  of  unfavorable  criticism  concerning 
this  excellent  book,  but  as  indicating  the  difficulties  which  must  be  insep- 
arable from  any  work  upon  surgical  diagnosis.  Mr.  Gould  has  met  these 
difficulties  of  his  task  well,  and  he  has  produced  a  good  book.  It  is  of  a 
convenient  size,  and  we  shall  be  much  mistaken  if  it  does  not  become  popu- 
lar. Mr.  Gould's  style  is  good,  and  he  is  endowed  with  that  rare  grace, 
modesty,  so  that  it  is  with  pleasure  we  add  that  he  is  to  be  congratulated 
upon  having  produced  a  valuable  contribution  to  surgical  literature. 

S.  A. 


Art.  XXXVII  The  Year  Booh  of  Treatment  for  1884.    8vo.,  pp.  308. 

Philadelphia:  Lea  Brothers  &  Co.,  1885. 

"  The  object  of  this  book  is  to  present  to  the  practitioner,  not  only  a  complete 
account  of  all  the  more  important  advances  made  in  the  treatment  of  disease,  but 
to  furnish  also  a  review  of  the  same  by  competent  authorities.  Each  department 
of  practice  has  been  fully  and  concisely  treated,  and  care  has  been  taken  to  in- 
clude such  recent  pathological  and  clinical  work  as  bears  directly  upon  treatment." 

The  "  year"  included  in  this  book  ends  Sept.  30,  1884.  After  carefully 
looking  over  the  book,  and  reading  a  number  of  the  principal  articles,  we 
can  endorse  the  statements  set  forth  in  the  portions  of  preface  wrhich  we 
have  quoted.  In  a  few  moments,  the  busy  practitioner  can  refresh  his 
mind  as  to  the  principal  advances  in  treatment  for  a  year  past,  advances 
which  are  regarded  as  such  by  J.  Lauder  Brunton,  Charles  Henry  Ralfe, 
Dyce  Duckworth,  J.  Mitchell  Bruce,  R.  Douglass  Powell,  F.  A.  Maho- 
med, Arthur  E.  Sansom,  and  others  in  the  various  departments  of  medi- 
cine ;  and  Bryant,  Treves,  Haward,  Edmund  Owen,  Reginald  Harrison, 
Alfred  Cooper,  J.  Knowsley  Thornton,  Champneys,  Henry  Power,  and  a 
number  of  well-known  practical  workers  in  the  field  of  surgery,  diseases  of 
women,  of  the  eye,  of  the  ear,  of  the  throat,  nose,  and  skin.  The  book 
concludes  with  a  general  summary  of  the  therapeutics  of  the  year  1883- 
1884  by  Walter  G.  Smith,  M.D.  This  kind  of  work  is  peculiarly  use- 
ful at  the  present  time,  when  current  medical  literature  is  teeming  with 
innumerable  so-called  advances,  which  the  average  practitioner  has 
neither  time  nor  experience  to  determine  the  value  of.  Here  he  has,  col- 
lected from  many  sources,  a  resume  of  the  theories  and  facts  which  are  new, 
either  entirely  or  in  part,  the  decision  as  to  their  novelty  being  made  by 
those  who  by  wide  reading  and  long  experience  are  fully  competent  to 
render  such  a  verdict.  C.  B.  N. 


1885.] 


557 


QUARTERLY  SUMMARY 

OF  THE 

IMPROVEMENTS  AND  DISCOVERIES 

IN  THE 

MEDICAL  SCIENCES. 


ANATOMY  AND  PHYSIOLOGY. 

Case  of  a  Hermaphrodite  aged  nine  years  with  the  external  ajyearances  of  a 
Female,  in  whom  both  Testicles  were  removed  from  the  Labia  Majora, 

Dr.  George  Buchanan,  in  the  Lond.  Med.  Times  of  February  14,  1885, 
reports  a  case  of  hermaphroditism  in  which  the  testicles  were  found  in  the  labia 
majora.  Grave  doubts  were  at  first  had  as  to  the  nature  of  the  case,  and  it  was 
thought  that  the  swelling  in  the  labia  might  be  caused  by  a  double  hernia  sac, 
each  containing  an  ovary.  This  however  seemed  improbable,  and  the  alternative 
suggested  itself  that  the  child  might  be  a  hermaphrodite,  externally  a  female, 
with  testicles  in  the  labia.  Nevertheless  the  external  organs  were  those  of  a 
female,  and  the  vagina,  nymphse,  clitoris,  meatus,  and  hymen  were  normal,  being 
exactly  as  would  be  expected  in  a  girl  nine  years  of  age. 

Examination  further  showed  that  on  touching  the  skin  on  the  front  of  the 
thigh  the  bodies  in  the  labia  Avere  immediately  drawn  up  close  to  the  inguinal 
ring,  thus  proving  the  existence  of  cremaster  muscles,  and  conclusively  showing 
them  to  be  testicles. 

Accordingly  the  patient  was  ana3Sthetized,  and  the  testicles,  which  were  con- 
tained in  unclosed  tunica?  vaginales,  removed  at  separate  operations  a  few 
weeks  apart. 

During  the  time  the  patient  was  under  the  influence  of  chloroform  a  complete 
examination  of  the  external  organs  was  made,  which,  as  has  been  said,  were 
perfectly  normal.  The  vagina  extended  the  usual  depth,  but  when  the  finger 
reached  the  extremity,  instead  of  the  os  uteri  there  was  a  vertical  septum,  on  each 
side  of  which  was  a  little  cul-de-sac  like  a  very  small  thimble.  The  only  other 
condition  dissimilar  to  the  normal  female  organs  was  the  existence  of  a  narrow 
slit  at  each  side  of  the  meatus  large  enough  to  admit  the  point  of  a  probe. 

Hypnotism, 

V  EncSphale  for  November  and  December  contains  an  interesting  study  upon 
hypnotism,  by  M.  August  Voisin,  of  which  the  following  are  the  conclu- 
sions :  — 

1.  Hypnotic  slumber  has  been  frequently  produced  by  fixing  the  attention  of 
the  patient  upon  some  organ,  as  the  eyes  ;   or  by  making  pressure  near  the  base 
No.  CLXXVIIL— April,  1885.  36 


558 


Progress  of  the  Medical  Sciences. 


[April 


of  the  nose  ;  or  by  apposition  of  the  hand  to  the  closed  eyelids  ;  or  by  the  effect 
of  the  magnesium  light  upon  the  eyes,  which  must  be  kept  open.  Sometimes  it 
is  necessary  to  follow  for  a  long  time  the  patient's  eyes.  These  procedures 
repeated  for  two  or  three  days  render  the  results  more  certain. 

2.  Each  hypnotic  slumber  is  preceded  by  sensations  of  dizziness,  and  heaviness 
of  the  eyelids,  or  by  nausea. 

3.  In  many  cases  the  initial  period  is  accompanied  by  shivering  and  trembling. 
These  are  only  produced  when  the  slumber  has  been  slow  in  appearing. 

4.  The  hypnotic  slumber  is  very  calm.  Anaesthesia  and  collapse  are  complete. 
The  patient  may  sleep  from  22  to  23  hours.  She  moves,  turns  upon  her  couch, 
and  speaks,  from  time  to  time,  when  disturbed.  Her  awakening  does  not  at  all 
resemble  that  of  a  person  arousing  from  a  natural  sleep.  Thus,  she  suddenly  sits 
up,  does  not  stretch  or  yawn,  but  arises  from  her  bed  as  if  to  leave  the  room. 
The  countenance  shows  no  sign  of  fatigue. 

5.  It  is  possible  to  suggest  during  each  slumber  divers  acts  to  be  performed  on 
awakening,  or  a  number  of  hours  or  days  thereafter.  Thus,  it  has  been  suggested 
to  a  patient  to  take  at  a  certain  hour  a  flask  of  wine  concealed  for  her,  or  to  carry 
an  object  to  a  comrade ;  also,  a.  patient  has  been  made  to  greet  a  sister,  to  whom 
heretofore  she  had  shown  the  greatest  animosity,  with  the  greatest  manifestations 
of  love  and  affection. 

6.  The  patient  being  directed  to  awake  at  a  given  hour,  will  do  so  in  spite  of 
protestations  to  the  contrary,  the  time  coinciding  with  the  striking  of  the  hours,  or 
a  very  few  minutes  after. 

7.  The  effect  of  hypnotic  slumber  frequently  produced  is  progressively  to -allay 
the  excitement  of  the  patient,  and  notably  to  diminish  disorders  of  action  and 
speech. 

8.  The  contrast  which  exists  between  incoherence  of  action  and  speech  during 
waking  hours  and  their  reasonable  character  during  the  slumber  is  worthy  of 
special  remark. 

9.  In  a  particular  patient  it  was  remarkable  that  during  the  persistence  of  the 
slumber  she  lamented,  without  suggestion  of  Yoisin,  her  questionable  manner 
of  life,  etc.  ;  but  awake,  she  spoke  only  of  rejoining  her  companions,  of  enjoying 
herself,  and  of  revelling. 

10.  The  question  suggests  itself  whether  it  is  not  possible,  by  means  of  hyp- 
notic slumber,  in  a  certain  variety  of  cases,  to  quiet  excitement,  and  give  to  the 
mind  a  moral  and  intellectual  inclination. 


Pathological  Physiology  of  the  Supra-Renal  Capsule. 

In  a  recent  number  of  the  Rivista  internaz.  di  Medicina  e  Chirurgia,  Tis- 
soni,  of  Bologna,  reports  a  series  of  experiments  made  by  him,  chiefly  with  the 
idea  of  clearing  up  the  pathology  of  Addison's  disease. 

He  propounds  the  following  questions  :  1.  What  are  the  relations  of  the  supra- 
renal capsule  to  the  cerebro-spinal  nervous  system  and  to  the  great  sympathetic  ? 
2.  What  is  the  reaction  of  the  capsules  to  excitants?  3.  By  what  process  do 
destruction  and  absorption  of  the  constituent  elements  of  the  parenchyma  of 
these  organs  take  place,  after  a  stimulation  so  great  as  to  profoundly  alter  their 
vitality  ?  4.  Is  partial  or  total  reproduction  possible  after  partial  or  total  de- 
struction, and  by  what  process  does  the  new  formation  take  place  ?  5.  Is  hyper- 
trophy of  one  capsule  possible  after  destruction  of  the  other?  If  so,  what 
parts  of  the  capsule  are  especially  interested  in  that  process,  and  what  are  the 
histological  facts  in  the  case  ?    6.  What  are  the  general  modifications  of  the  organ- 


1885.] 


Anatomy  and  Physiology. 


559 


ism,  particularly  that  related  to  the  pigmentation  of  the  skin  and  the  mucous 
membranes,  which  tend  directly  to  the  destruction  of  one  or  both  capsules  ? 

Tissoni  operated  on  31  rabbits,  after  having  perfected  himself  in  the  operative 
technique.  The  duration  of  the  experimental  watch  over  each  rabbit  varied 
from  21  to  219  days.  Of  the  31  rabbits,  only  5  were  killed,  the  experimenter 
confining  himself  to  the  exposition  of  the  gross,  macroscopical  phenomena  ob- 
served in  the  course  of  his  experiments,  and  to  giving  a  summary  of  the  micro- 
scopical appearances  in  the  few  animals  killed,  or  which  died  in  twenty  days  after 
being  operated  on.  Of  the  animals  that  died  in  consequence  of  the  operation, 
Tissoni  could  find  no  lesions  which  might  be  described  as  special  to  the  operation 
— as  Brown-Sequard  claimed.  The  majority  died  of  subcutaneous  and  intra- 
muscular suppuration,  which  had  formed  in  these  situations  as  a  thick  bed  of 
pus,  a  sort  of  false  membrane  which  invaded  a  large  portion  of  the  dorsal  region. 

In  some  of  the  rabbits  there  was  contracture  of  one  of  the  limbs,  anterior  or 
posterior,  which  disappeared  in  a  few  days  in  some  cases,  but  which  was  followed 
by  paralysis  and  death  in  others.  The  post-mortem  examination  of  these  animals 
showed  an  exudative  meningitis,  and  softening  of  the  spinal  cord.  With  the 
exception  of  these  few  cases,  the  operation  was  followed,  in  the  greater  num- 
ber of  cases,  by  no  serious  consequences.  The  animals  walked  about  and  ate, 
and  seemed  perfectly  healthy  during  the  whole  time  of  observation.  The  results 
of  the  operations  did  not  seem  to  be  affected  by  the  leaving  of  the  capsule  in  the 
peritoneal  cavity.  On  the  contrary,  in  a  few  cases  in  which  the  capsule  was  left, 
the  rabbits  seemed  to  recover  more  promptly,  nor  was  the  absorption  of  the  cap- 
sule, which  was  complete  when  the  animals  were  killed,  attended  by  any  modifi- 
cation of  the  temperature,  or  any  other  unusual  symptoms.  "Hence,"  says 
Tissoni,  "  the  fact  that  the  capsules  could  be  absorbed  without  causing  toxic  phe- 
nomena at  once  disposes  of  the  possibility  of  their  containing  a  virus,  or  of  Addi- 
son's disease  being  a  sort  of  cachexia,  due  to  altered  secretion  of  the  capsule  or 
the  product  of  the  retention  in  the  blood  of  certain  principles  which,  under  nor- 
mal conditions,  is  taken  up  by  the  capsules,  and  becomes  a  toxic  substance." 

The  first  thing  noticeable  after  the  Qperation  was  the  brown  discoloration  of 
the  mucous  membranes  ;  and  soon  after  this,  pigmented  spots  on  the  buccal  and 
nasal  mucous  membrane,  which  commenced  as  small  points,  the  color  of  tobacco, 
which  grew  larger,  became  confluent,  then  brown,  then  bronze-colored,  and 
finally  all  the  characteristics  of  Addison's  disease.  The  spots  on  the  lower  lip 
were  sometimes  isolated  more  after  they  formed  a  black  line  which  ran  around  the 
mouth.  The  pigmentation  of  the  mouth  was  very  frequent,  and  very  important. 
Tissoni  considers  it  worthy  of  remark  that  the  abnormal  pigmentation  appeared 
after  the  removal  of  one  capsule  only,  as  well  as  after  removal  of  both.  But  in 
the  first  case  the  pigmented  spots  were  found  almost  exclusively  on  the  operated 
side,  though  in  some  instances  they  crossed  to  the  other  side. 

It  seems  evident,  therefore,  or  experimentally  proved:  1.  That  the  supra- 
renal capsules  take  part  in  the  distribution  of  pigment.  2.  That  the  variations  in 
the  color  of  the  skin  and  mucous  membranes  may  occur  after  the  destruction  of  one 
or  both  capsules.  3.  That,  with  the  exception  of  this  abnormal  distribution  of 
pigment,  the  animals  (rabbits),  from  which  one  or  both  capsules  have  been  re- 
moved, remain  perfectly  healthy,  and  may  live  a  long  time.  The  alteration  in 
the  distribution  of  the  pigment  is  then  the  only  thing  obtained  by  removing  the 
capsules  ;  the  clinical  phenomena  of  Addison's  disease  were  not  produced.  Re- 
generation of  the  capsule  was  observed  in  two  cases.  When  only  one  capsule 
was  removed,  there  was  a  subsequent  hypertrophy  of  the  cortical  substance  of 
the  other,  rather  than  of  the  medullary  substance. — L'  Union  M6d.,  November 
6,  1884. 


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The  Influence  of  Nervous  and  Muscular  Work,  and  of  Fatigue  upon  the  Tendon 
Reflexes  and  Electro- Excitability  of  the  Muscles  in  Man. 

Dr.  J.  Oeschansky,  after  a  long  series  of  experiments,  relative  to  the  influ- 
ence of  nervous  and  muscular  work,  and  fatigue  upon  the  tendon  reflexes,  and 
electro-excitability  of  the  muscles,  arrives  at  the  following  conclusion  : — 

1.  Galvanic  and  Faradic  contractility  is  augmented  at  the  beginning  of  labor, 
but  afterwards  as  the  muscles  become  more  and  more  fatigued  it  diminishes. 

2.  In  the  reaction  of  degeneration  there  is  often  observed  a  notable  diminution 
of  Faradic  contractility,  with  normal  conservation  of  galvanic  contractility. 

3.  Muscular  contraction  becomes  feebler  the  longer  work  is  continued. 

4.  These  phenomena  are  noticeable  upon  all  muscles  which  have  undergone 
either  tonic  or  clonic  contraction. 

5.  Like  phenomena  are  observed  in  the  nerves,  but  after  a  much  longer  time. 
They  therefore  are  less  easily  fatigued  than  the  muscles. 

6.  Muscular  excitability  returns  more  quickly  when  lost  than  does  nervous. 
A  constant  current  must  be  used  to  produce  such  effect. 

7.  The  tendon  reflexes  are,  in  incipient  fatigue,  exaggerated,  but  gradually 
decrease  as  strength  diminishes,  and,  finally,  may  altogether  disappear.  They, 
however,  are  more  quickly  restored  than  muscular  contractility. 

The  author  considers  patellar  reflex  to  be  muscular,  not  nervous  in  its  origin. 

New  Methods  for  Testing  Urine. 

In  the  last  session  of  the  Vienna  Medical  College,  Dr.  V.  Jaksch  called 
attention  to  some  new  methods  of  examining  the  urine  for  various  substances.  In 
most  cases  there  exists  not  only  one,  but  two  albuminous  substances  in  the  urine, 
namely,  serumalbumin  and  globulin,  and  sometimes,  also,  ox y- haemoglobin, 
fibrin,  and  pepton.  Pure  globulinuria  was  observed  only  in  one  instance  by 
Kiihn.  To  determine  whether  the  urine  contains  serumalbumin,  pepton,  or  pro- 
peptone,  three  reactions  must  be  practised.  1.  The  urine  is  boiled,  and  nitric  acid 
is  added  ;  if  the  resulting  precipitate  contain  albumen,  after  the  addition  of  the 
acid,  it  will  not  disappear,  but  remain  flaky.  2.  The  next  step  is  to  add  acetic 
acid  in  excess  to  the  filtered  urine,  and  afterwards  add  solution  of  potassium 
ferrocyanide.  If  albumen  be  present,  excessive  cloudiness  results.  3.  The 
third  test  consists  of  the  addition  of  liquor  potassa  and  sulphate  of  copper  to  the 
urine.  The  mixture  by  boiling,  becomes  of  a  violet  color.  If  now  the  first  test 
give  negative,  and  the  second  positive  results,  the  existence  of  propeptone  is 
very  probably  assured.  It  is  positively  indicated  by  the  presence  of  precipitate 
after  the  addition  of  sodium  chloride  and  acetic  acid.  If  the  urine  contain  pep- 
tone, both  first  and  second  tests  will  fail,  but  the  third  will  give  positive  results. 
If  a  small  amount  of  peptone  be  present,  and  the  urine  free  from  mucin — which 
is  accomplished  by  the  addition  of  acetic  acid— there  will  result  a  precipitate  upon 
the  addition  of  acetic  acid  and  phospho-tungstic  acid.  Albuminuria  is  of  much 
prognostic  importance.  In  hypertrophy  of  the  heart,  without  excitation  or 
murmur,  if  the  urine  give  a  precipitate  with  acetic  acid  and  potassium  ferro- 
cyanide, contraction  of  the  kidneys  may  be  diagnosticated  along  with  degeneration 
of  the  arteries  and  consecutive  red  atrophy  of  the  kidneys.  The  signification  of 
propeptonuria  in  any  disease  is  not  recognized.  Through  the  labors  of  Schmidt, 
Miihlhain,  and  Hofroaier  it  has  been  demonstrated  that  the  white  blood-cor- 
puscles are  peptone  carriers.  Peptonuria  follows  ulceration  of  the  colon,  ulcerous 
carcinoma  of  the  stomach,  the  decay  of  pus-corpuscles  in  the  body  from  white 
blood-corpuscles  in  the  circulation  ;  from  scorbutus  ;  in  puerperal  fever  ;  deep- 


1885.] 


Materia  Medica  and  Therapeutics. 


561 


seated  suppuration  ;  and,  finally,  in  cerebrospinal  meningitis,  a  point  of  dis- 
tinction from  tuberculous  meningitis.  Dr.  Jaksch  next  mentions  liquor  potas- 
sium as  a  test  for  sugar,  and  the  brown  coloration  which  results  upon  boiling  it 
with  urine  containing  sugar  ;  also,  the  Trommer's  test,  and  remarks  that  because 
these  tests  are  not  sufficiently  reliable,  Penozldt's  test  should  also  be  used. 
This  consists  in  the  addition  of  diazobenzene  sulphonic  and  acetic  acid  to  the 
suspected  urine  ;  if  sugar  be  present  an  intensely  red  color  with  marked  turbidity 
results.  As  an  entirely  reliable  test,  Jaksch  also  recommends  that  of  von  Fischer 
with  phenilhydracin.  Finally,  Redner  discussed  the  methods  for  the  detection 
of  the  acetons,  which  appear  in  the  body  during  the  existence  of  fevers,  inanition, 
and  carcinoma. —  Wien.  Med.  Wochenschr.,  December  6,  1884. 


MATERIA  MEDICA  AND  THERAPEUTICS. 

Antipyrin. 

HucHjARD,  in  a  therapeutic  study  of  "antipyrin,"  which  appears  in  L'  Union 
MSdicale,  Dec.  6,  1884,  reaches  the  following  conclusions:  — 

1.  Antipyrin  is  a  powerful  and  certain  means  of  reducing  the  temperature  in 
almost  all  febrile  diseases  (typhoid  fever,  phthisis  pulmonalis,  pneumonia,  pleu- 
risy, acute  articular  rheumatism,  cerebral  rheumatism,  erysipelas,  diphtheria, 
puerperal  fever,  scarlatina,  abscess,  phlegmon,  etc.).  It  mitigates  the  symp- 
toms which  depend  upon  the  elevation  of  temperature  (acceleration  of  the  pulse, 
and  of  respiration,  dryness  of  the  mouth),  but  does  not  appear  to  have  any  direct 
action  upon  the  respiration  and  circulation. 

2.  Antipyrin  is  an  antipyretic  and  not  an  antiperiodic,  and  is,  therefore,  ineffi- 
cacious to  prevent  the  recurrence  of  intermittent  fevers. 

3.  Its  administration  gives  rise  sometimes  to  slight  discomfort,  such  as  light 
sweating,  constriction  of  the  pharynx,  nausea  and  vomiting,  and,  in  rare  cases, 
to  rubeolous,  or  scarlatinous  exanthems.  There  is  no  tendency  to  collapse,  or  in- 
toxication, as  after  the  administration  of  preparations  of  quinia,  or  the  salicylates. 

4.  Numerous  observations  show  that  antipyrin  is  the  most  powerful  and  up  to 
this  time  the  only  known  means  of  successfully  reducing  the  temperature  of 
tuberculosis.  In  a  dose  of  30  grains  administered  in  the  evening,  at  the  appear- 
ance of  the  fever,  the  temperature  decreases  a  half  degree  in  half  an  hour,  some- 
times in  a  quarter  of  an  hour,  and  then  diminishes  progressively  to  normal  in  an 
hour  and  a  half  or  two  hours.  It  is,  however,  sometimes  necessary  to  prescribe, 
an  hour  or  two  later,  a  second  dose  of  15  or  20  grains.  But  in  consumptives, 
antipyrin,  by  reason  of  the  surety  of  its  action,  and  with  the  aim  to  escape 
accidents  produced  by  abnormally  low  temperature,  should  be  administered  in 
small  but  increasing  doses  (30  to  60  grains). 

5.  The  apyretic  effect  is  maintained  ordinarily  from  six  to  nine  hours,  and  is 
felt  sometimes  during  several  succeeding  days,  during  which  the  temperature 
does  not  attain  its  former  elevation.  The  secondary  rise  of  temperature  is  pro- 
gressive, following  in  this  respect  the  progress  of  defervescence.  It  is  not  sudden, 
as  that  produced  by  kairin,  and  is  never  accompanied  by  a  chill  more  or  less 
prolonged. 

6.  Antipyrin  is  eliminated  by  the  urine,  where  its  presence  is  recognized  in 
from  two  to  four  hours  after  its  administration,  during  a  period  which  varies 


562 


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from  thirty-six  to  forty-eight  hours.  A  few  drops  of  the  perchloride  of  iron 
mixed  with  the  urine  of  patients  treated  with  the  drug  cause  at  once  a  red  colora- 
tion, which  is  very  characteristic. 

7.  Huchard  has  not  yet  employed  antipyrin  in  typhoid  fever,  but,  according 
to  foreign  authors,  it  is  necessary  to  employ  doses  of  from  75  to  91  grains  daily 
(30  grains  at  the  interval  of  an  hour,  and  15  or  30  the  third  hour).  Under 
the  influence  of  these  doses  the  reduction  of  temperature  is,  for  the  first  hour,  a 
minimum,  1.8°  F.,  and  a  maximum  of  3.6°,  and  continues  to  fall  until  the 
seventh  or  eighth  hour.  Frequently  at  the  fifteenth  or  sixteenth  hour  rises  again 
about  1.8°,  and  again  falls  regularly.  This  mild  rise  of  temperature  has  been 
noticed  also  by  us  during  the  action  of  antipyrin  upon  the  fever  of  phthisis. 

8.  In  typhoid  fever,  doses  of  from  90  to  120  grains,  directed  by  some  writers, 
appear  to  us  too  large,  since  they  bring  on  a  temperature  abnormally  low.  In 
cases  recorded  by  P.  Snyers,  seven  or  eight  hours  after  the  administration  of 
the  drug  there  was,  in  nine  cases,  a  temperature  below  96.8°  ;  in  ten,  below  95°  ; 
in  four,  below  93.1°;  and  in  one,  below  91.4°. 

Employment  of  Hydro  chlorate  of  Cocaine  in  Obstetrics. 

Dr.  Alphonse  Herrgott,  after  a  comparative  study  of  many  reports  con- 
cerning the  use  of  hydrochlorate  of  cocaine  in  obstetrics,  and  after  numerous  ex- 
periments of  his  own,  in  which  the  effects  of  the  drug  were  carefully  noted, 
reaches  the  following  practical  conclusions  as  to  its  value  :  — 

1.  Sensibility  to  pain  was  always  very  markedly  diminished.  Only  moderate 
pain  was  felt,  which  was  almost  nil  in  superficial  parts  and  much  diminished  in 
the  deeper  tissues. 

2.  Cocaine  also  entirely  anaesthetizes  an  inflamed  mucous  membrane,  as  is 
shown  by  its  effects  in  vulvitis  and  acute  genorrhceal  vaginitis. 

3.  Reflex  vaginal  excitation  is  diminished  by  application  of  the  drug. 

The  preceding  effects  having  been  noted,  the  general  indications  for  the  use  of 
cocaine  may  be  summarized  as  follows  :  — 

1.  To  produce  anaesthesia. — a.  Before  extensive  cauterization  of  the  vulvar  or 
vaginal  mucous  membrane,  or  before  the  application  of  caustic,  or  concentrated 
solutions  of  corrosive  sublimate. 

b.  Before  the  removal  of  small  superficial  vegetations  of  the  vulvar  mucous 
membrane  :  for  example,  in  condylomata  or  caruncles  of  the  urethra. 

c.  In  excitable  patients,  in  cauterization  of  the  uterine  neck  or  previous  to  the 
use  of  the  curette  in  the  uterine  cavity. 

2.  To  diminish  reflex  excitement. — a.  In  case  of  temporary  vaginismus,  before 
the  touch,  or  introduction  of  a  vaginal  speculum,  or  even  by  the  patient  herself 
before  coitus. 

b.  In  case  of  spasm  of  the  rectum  and  anus  occasioned  by  fissure,  either  for 
operative  procedures  without  general  anaesthesia,  or  for  the  relief  of  pain  during 
defecation. — Annates  de  Gynecologic  et  d'  Obstetrique,  Feb.  1885. 

Cerebral  Symptoms  from  Subcutaneous  Injection  of  Hydrochlorate  of  Cocaine. 

At  a  recent  meeting  of  the  Society  de  Thgrapeutique,  M.  Dujardin-Beau- 
metz  called  attention  to  an  accident  which  may  result  from  the  subcutaneous 
injection  of  hydrochlorate  of  cocaine. 

The  chief  of  his  laboratory  after  such  injection  experienced  a  feeling  of  syn- 
cope and  two  similar  cases  have  also  been  observed  by  him.  Another  patient 
experienced  strange  sensations,  along  with  cerebral  excitement. 


1885.] 


Materia  Medica  and  Therapeutics. 


563 


The  degree  of  concentration  of  the  solution  seemed  to  have  no  influence  upon 
its  action.  Dujardin-Beaumetz  attributes  the  peculiar  effects  observed,  to  cere- 
bral anaemia,  since  they  were  not  noticeable  when  the  patient  was  reclining  when 
the  injection  was  administered. — Gazette  Hebdomadaire  de  M6d.  et  de  Chirurg., 
Feb.  6,  1885. 

Thallin  as  an  Antipyretic. 

Dr.  C.  Alexander,  after  carefully  observing  the  effect  of  thallin  in  reducing 
temperature,  states  the  following  in  reference  to  its  action.  In  almost  all 
instances,  the  pulse-rate  diminishes  in  frequency  along  with  the  lowering  of 
temperature,  after  the  administration  of  thallin  or  its  salts. 

The  pulse-rate  is,  however,  not  markedly  influenced  as  the  temperature,  and 
almost  never  is  reduced  to  normal ;  sometimes  it  remains  unaffected,  but  no  un- 
favorable cardiac  symptoms  ever  follow  the  use  of  the  drug. 

In  the  greater  number  of  cases  lowering  of  temperature  is  accompanied  by 
general  perspiration.  Seldom  indeed  was  perspiration  entirely  absent,  and  was 
not  excessive  except  only  in  a  single  case  of  phthisis. 

The  antipyretic  effect  of  the  drug  is  observed  also  in  those  cases  in  which  per- 
spiration is  absent. 

The  duration  of  the  abatement  of  temperature,  caused  by  a  single  dose  of  4 
grains  of  thallin,  is  short,  seldom  lasting  more  than  four,  and  usually  but  two  or 
three  hours.  A  second  dose  again  reduces  the  temperature  to  normal  ;  but  in 
from  three  to  five,  and  sometimes  even  in  two  hours,  it  once  more  begins  to  rise. 

When  the  drug  is  discontinued,  the  temperature  returns  to  its  former  height 
within  two  to  four  hours. — Centralbl.  fur  Klin.  Med.,  Feb.  7,  1885. 

Therapeutics  and  Action  of  Euphorbia  Pelulifera. 

Marset  summarizes  the  action  and  therapeutics  of  Euphorbia  pilulifera  as 
follows :  — 

1.  The  active  principle  of  Euphorbia  pilulifera  is  soluble  in  water  and  dilute 
alcohol,  insoluble,  or  nearly  so  in  ether,  chloroform,  sulphide  of  carbon  and  oil  of 
turpentine. 

2.  It  is  toxic  in  weak  doses  to  the  small  animals,  which  it  kills  by  arresting 
respiration  and  stopping  the  pulsations  of  the  heart,  which  are  at  first  accelerating, 
but  gradually  cease  under  its  influence. 

3.  Its  effects  are  not  cumulative. 

4.  It  appears  to  act  directly  upon  the  cardiac  and  respiratory  centres,  to  which 
its  influence  is  limited. 

5.  It  appears  to  be  eliminated  by  the  liver. 

6.  Locally,  it  is  without  action  upon  the  skin  and  mucous  membranes,  except 
upon  the  gastric  mucous  membrane,  which  it  irritates. 

7.  It  gives  good  results  in  attacks  of  dyspnoea  caused  by  asthma,  emphysema, 
or  chronic  bronchitis  in  abundant  watery  solution,  taken  preferably  immediately 
before  meals. 

The  aqueous  or  alcoholic  extract  is  a  good  preparation.  A  grain  daily  is  the 
maximum  dose  employed,  and  frequently  five-sixths  of  a  grain  have  produced 
marked  results. — V  Abeille  J\l6dicale,  Jan.  26,  1885. 

New  Apparatus  for  Transfusion  of  Blood. 

Dr.  Vleminckx  attributes  the  success  of  the  operation  performed  by  him  to 
the  perfection  of  the  apparatus  employed,  a  description  of  which  is  given  in  detail : 


564 


Progress  of  the  Medical  Sciences. 


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The  apparatus  of  Dr.  Casse  consists  of  a  graduated  cylindrical  receiver,  capable 
of  containing  about  four  ounces  and  a  half  of  defibrinate  ;  to  the  lower  extremity 
of  this  cylinder  a  rubber  tube,  about  a  metre  in  length,  is  fitted.  A  section  of 
glass  tubing,  in  the  rubber,  enables  the  blood  to  be  seen  during  operation.  The 
end  of  the  rubber  tube  is  so  arranged  as  to  fit  the  canula  which  is  introduced  into 
the  vein.  To  operate,  blood  is  drawn  from  the  donor,  and  whipped  about  fifteen 
minutes  with  a  small  rod,  and  the  fibrin  thus  collected  is  removed.  In  the  mean 
while  the  vein  of  the  patient  is  exposed,  and  the  canula  introduced  into  which  the 
tube  is  shortly  to  be  fitted.  All  being  in  readiness,  there  is  placed  in  the  graduated 
vessel  a  funnel  covered  with  flannel,  upon  which  the  defibrinated  blood  is  poured 
little  by  little  until  it  reaches  the  distal  extremity  of  the  rubber  tube,  it  is  fitted 
into  the  canula,  and  the  operation  begins.  It  is  certain  no  air  can  enter  the  ves- 
sels, and  the  orifice  of  the  canula,  which  is  almost  a  capillary  tube,  permits  the 
blood  to  enter  with  extreme  mildness.  The  vessel  containing  the  blood  is  placed 
a  little  above  the  level  on  which  the  patient  lies,  so  that  by  the  force  of  gravity 
only  the  blood  is  made  to  enter  the  vein.  Any  fibrin  which  has  chanced  to  re- 
main is  retained  by  the  flannel  upon  which  the  blood  is  poured.  When  the  ves- 
sel is  empty,  the  tube  is  withdrawn  from  the  canula,  and  the  air  is  thus  excluded 
from  the  vein.  This  done,  the  canula  is  removed  from  the  vein,  and  a  dressing 
applied  over  the  part.  The  advantages  of  this  method  are  numerous.  By  the 
precautions  taken  air  is  prohibited  from  entering  the  vein,  as  is  also  the  fibrin  ; 
the  extreme  gentleness  with  which  the  blood  enters  the  vein  permits  the  current 
to  adjust  itself  to  the  new  supply.  Finally,  by  using  the  apparatus  it  is  possible 
to  operate  extemporaneously  without  having  recourse  to  warm  vessels,  which 
must  be  kept  at  a  uniform  temperature  when  blood  not  defibrinated  is  used. 
Further,  the  microscope  shows  that  the  blood-globules  are  not  altered  in  shape, 
and  the  results  obtained  prove  that  they  have  lost  none  of  their  properties,  and 
that  the  introduction  of  them  alone  without  fibrin  is  sufficient  to  restore  vitality. 
— Revue  Mgdicale,  Jan.  2,  1885, 


MEDICINE. 

The  Etiology  of  Asiatic  Cholera. 

Gazetti  Degli  Ospitali,  1884,  No.  92,  contains  a  resum6  of  the  conclusions 
reached  by  Ceci  and  Klebs,  after  their  investigations  as  to  the  etiology  of 
Asiatic  cholera.    They  are  as  follows  : — 

(1)  The  common  bacilli  are  not  regularly  found  in  the  choleraic  discharges,  or 
in  the  colon  of  those  dying  from  cholera.  For  this  reason,  if  not  their  patho- 
logical significance,  at  least  their  diagnostic  value  is  questionable. 

(2)  If  the  common  bacilli  are  found  in  the  discharges,  they  are  always  mingled 
with  short  spirilla,  which  exhibit  the  union  of  two  or  three  bacilli. 

(3)  If  the  bacilli-containing  discharges  are  permitted  to  stand  at  an  ordinary 
temperature,  on  the  second  day  the  spirillas  increase  considerably  in  size  and 
number ;  on  the  third  and  fourth  days,  a  true  pure  culture  of  spirillae,  some  of 
which  are  of  extraordinary  length,  shows  from  ten  to  thirty  curves.  During  the 
following  days  the  spirillar  diminish  rapidly,  and  are  replaced  by  some  oval  and 
somewhat  long,  putrefactive,  schidzomyceta?.  (C.) 

(4)  The  same  bacilli  may  originate  from  division  of  the  spirilla?.  Under  the 
microscope  spirilla;  may  be  plainly  seen,  which,  while  dividing  into  five  or  six 


1885.] 


Medicine. 


565 


bacilli  at  one  end,  at  the  other  maintain  their  continuity.  Probably,  therefore, 
the  spirilla3,  while  they  are  lengthening,  form  the  common  bacilli.  Spores,  lat- 
terly, were  not  found.  (C.) 

(5)  During  the  growth  of  the  spirillae  the  discharges  remain  alkaline  or  neu- 
tral, and  the  reaction  does  not  change  by  the  progress  of  decomposition,  even  if 
the  spirilla?  and  bacilli  are  not  more  directly  recognizable. 

(6)  The  prime  invasion  of  cholera  is  confined  to  the  intestinal  canal.  Neither 
the  blood,  spleen,  liver,  nor  kidneys  contain  bacilli  or  other  micro-organisms. 

(7)  Even  in  the  algid  state  of  expiring  patients  no  common  bacilli  are  found 
in  the  breath. 

(8)  Even  in  the  algid  state  no  morphological  changes  are  found  in  the  blood, 
except  an  increase  in  the  white  blood  and  a  darker  appearance  of  the  red  corpus- 
cles, in  consequence  of  cyanosis. 

(9)  Though  no  bacilli  could  be  directly  discovered  in  discharges  in  which  pu- 
trefactive changes  had  occurred,  they,  however,  were  recognized  after  pure 
culture  had  been  made.  (C.) 

(10)  The  symptoms — death  and  tissue  change  in  cases  of  cholera,  running  in 
a  rapid  course — are  not  explainable  by  the  insignificant  intestinal  lesions  which 
are  present.  In  entirely  recent  cases  no  common  bacilli  were  found  in  the  folli- 
cles of  Lieberkiihn  ;  nevertheless  the  mucous  membrane  was,  to  a  great  extent, 
perforated  by  lymph-cells.  (K.) 

(11)  The  most  important  anatomical  lesions  are  found  in  the  kidneys,  which 
externally  have  no  abnormal  appearance  outside  of  the  pale  color  of  the  cortical 
substance.  If  the  preparations  are  colored  with  gentian  violet,  it  is  seen  that  the 
uriniferous  tubules  are  either  not  colored  or  else  easily  lose  the  staining  in  alcohol, 
and  that  the  medullary  substance  entirely  fades,  or  else  contains  only  a  trace  of 
the  coloring  material.    The  epithelium  has  undergone  coagulation  necrosis.  (K.) 

(12)  Ceci  affirms  that  the  common  bacilli  and  the  spirillse  of  Asiatic  cholera 
are  morphologically  identical  with  the  bacilli  and  spirillse  which  Finkler  and 
Prior  have  exhibited  from  the  culture  of  cholera  morbus,  and  brought  to  Genoa. 
Klebs  has  seen  the  same  forms  of  spirilla?  in  the  diarrhoea  of  pneumonic  patients. 

Both  Ceci  and  Klebs  arrive  at  the  conclusion  that  in  Asiatic  cholera  there  is 
probably  developed  a  substance  which  the  cell  protoplasm  seizes  upon ;  that  this 
substance,  which  probably  is  formed  by  agency  of  the  spirillae  in  the  intestine,  is 
absorbed,  and  in  slight  concentration  produces  an  atrophic  condition  of  the  tissues 
(spleen,  liver,  skin,  etc.),  and  in  stronger  concentration,  a  direct  necrosis  (as  in 
the  spleen).  A  series  of  severe  nervous  manifestations  is  to  be  considered  as 
uraemic,  as  Maragliano  also  assumes. 

Arterial  thrombosis — the  drying  of  the  conjunctiva,  pericardium  and  skin,  are 
to  be  attributed  to  the  decreased  cell  activity.  They  see  proof  of  the  correctness 
of  these  views,  in  the  fact  that  all  these  pathological  appearances  were  observed 
in  cases  of  cholera  sicca,  which  in  Genoa  were  especially  numerous. 

Further  investigation  will  be  made  with  the  object  of  recognizing  the  poison- 
ous principle. — Centralbl.  fur  Klin.  Med.,  Jan.  10,  1885. 

New  Therapeutic  Researches  upon  the  Asiatic  Cholera  of  1884. 

Dr.  M.  Semmola,  Professor  in  the  University  of  Naples,  and  Chief  Physician 
of  the  Hospitals,  in  an  important  communication  to  the  Bulletin  Gen.  de  The'ra- 
peutique,  December  15,  1884,  expresses  the  following  views  on  cholera  and  its 
treatment. 

Even  while  admitting  the  theory  of  the  microbe,  according  to  the  conclusions 
of  Dr.  Koch,  yet  I  am  convinced  that  that  theory  can  never  be  taken  as  a  point 


566 


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[April 


of  departure  for  the  rational  and  scientific  treatment  of  cholera.  Hence,  I  do 
not  hesitate  to  conclude,  after  observations  made  upon  a  large  scale,  that  the 
anti-microbe  or  anti-parasitic  treatment  is  not  at  all,  and  never  will  be,  the  proper 
method  by  which  to  arrest  the  development  of  the  disease,  and  for  the  following 
reasons : — 

(a)  Because  the  best  known  and  most  powerful  parasitic-destroying  agents 
can  never  be  introduced  into  the  intestinal  canal  in  proportions  necessary  to  kill 
the  microbe,  without  danger  to  the  patient. 

(b)  Because,  even  if  one  could  introduce  into  the  jejunum  a  sure  parasiticide, 
inoffensive  to  man,  the  death  of  the  microbe  would  constitute  but  a  small  portion 
of  the  treatment,  because  the  principal  phenomena  of  cholera  are  undoubtedly  due 
to  a  chemical  principle  (ptomaine),  which  poisons  successively  the  nerve-centres, 
and  which  is  in  the  course  of  formation  in  the  intestine  when  the  diarrhoea  advises 
us  that  the  choleraic  attack  has  commenced.  I  believe,  also,  that  the  diarrhoea 
itself,  from  its  beginning,  instead  of  being  an  irritating  effect  due  to  the  microbe, 
cannot  be  looked  upon  as  the  first  result  of  the  poisoning  of  the  abdominal  sym- 
pathetic nerve-centres,  through  their  incontestable  influence  upon  the  circulation, 
and  the  nourishing  of  the  intestine. 

It  is  possible  thus  to  explain  perfectly  the  hyperasmia  {rouge  hortensia)  of  the 
mucous  membrane,  the  profound  change  in  the  intestinal  epithelium,  and  the  dis- 
turbances of  secretion  which  constitute  the  first  stage  of  the  sickness. 

Hence,  even  admitting  the  parasitic  point  of  departure,  the  infection  due  to 
the  microbe  would  begin  its  deadly  work  in  the  intestine,  as  a  hidden  enemy, 
who  prepares  the  materials  of  its  attacks,  which  are  then  absorbed,  in  order  to 
produce  progressively  the  poisoning  of  the  different  nerve-centres  presiding  over 
the  functions  'successfully  disturbed. 

Anti-parasitic  treatment,  recommended  hitherto,  is  but  scientific  charlatan- 
ism.   Experiments  prove  nothing. 

The  specific  remedy  in  cholera  has  not  yet  been  discovered,  and  never  will  be 
by  means  of  laboratory  investigation. 

It  is  an  error  to  confound  the  infection  of  cholera  with  the  infection  of  marsh 
fever.  The  two  diseases,  in  Cochin  China,  raging  at  the  same  time,  were  distin- 
guished from  each  other  by  the  salts  of  quinine  curing  marsh  fever,  and  having 
no  effect  on  cholera. 

There  are  only  two  ways  to  treat  cholera,  i.  e.,  the  symptomatic  and  the  phy- 
siological treatments. 

By  symptomatic  treatment  the  physician  should  endeavor  to  combat  the  symp- 
toms as  they  arise  by  the  administration  of  medicinal  substances  which  presuma- 
bly exert  an  influence  opposed  to  the  conditions  observed.    Thus,  for  example  : — ' 

Intestinal  flux :  astringents. 

"Weakness :  stimulants. 

Algidity  :  artificial  heat ;  alcohol. 

Paralysis  of  the  heart :  injections  of  sulphuric  ether,  or  other  substances. 

But  if  the  physician,  seeing  the  persistence  and  the  aggravation  of  the  symp- 
toms he  wishes  to  combat,  redoubles  his  efforts  by  employing  remedies  which 
exert  a  disturbing  action  upon  the  economy,  he  aggravates  the  condition  of  the 
patient.  This  is  conspicuously  evident  in  the  use  of  such  remedies  as  atropia 
and  strychnia.  Physiological  treatment  is  most  to  be  considered.  It  comprises 
such  means  as,  without  exercising  a  disturbing  influence  upon  the  system,  may 
fortify  it  against  the  invasion  of  the  choleraic  poison. 

Under  this  head  may  be  considered  :  — 

(a)  Absolute  rest  of  the  organs  attacked,  that  is,  of  the  gastro-intestinal 
canal,  by  complete  fast  as  soon  as  the  first  diarrhoeic  symptom  is  manifested.  I 


1885.] 


Medicine. 


567 


do  not  think  this  point  has  been  sufficiently  dwelt  upon,  and  I  repeat  that  after 
the  first  appearance  of  diarrhoea,  even  the  smallest  quantities  of  ingested  food 
constitute  a  veritable  mitrailleuse,  which  we  put  into  the  hands  of  the  enemy. 
This  functional  rest  should  be  continued  until  complete  reaction  has  set  in.  I 
have  observed  that  milk,  in  small  quantities,  is  the  most  preferable  substance 
with  which  to  begin  alimentation. 

(b)  Stimulate  the  economy  opportunely  by  physiologically  therapeutic  means. 
Heat,  applied  in  the  form  of  warm  baths  (temperature  of  100f°  to  104°  F.),  re- 
peated according  to  necessity,  answers  the  requirement.  I  have  said  opportunely. 
The  most  favorable  time  to  use  the  hot  bath  is  before  the  algid  condition  has 
begun,  because  it  is  impossible  to  restore  the  heat  to  a  cutaneous  surface,  once  so 
chilled.  To  maintain  the  good  effects  of  the  warm  baths,  they  should  be  re- 
peated in  from  one  to  two  hours,  according  to  the  judgment  of  the  physician,  and 
the  patient  should  afterward  be  wrapped  in  coverings  of  wool  and  receive  hot 
aromatic,  or  weak  alcoholic  drinks. 

Should  a  patient,  suffering  from  even  a  slight  diarrhoea,  begin  to  experience 
epigastric  pain,  with  or  without  vomiting,  the  hot  bath  is  to  be  renewed  without 
delay,  and  continued  ten  or  fifteen  minutes. 

Further,  in  cases  of  simple  diarrhoea  without  epigastric  symptoms,  which  are 
rebellious  to  the  initial  treatment  (rest,  absolute  fast,  opium,  tannin,  etc.),  I 
advise  the  hot  bath,  with  necessary  precautions.  I  have  seen  hundreds  of  cases 
rebellious  to  treatment  for  several  days,  yield  to  one  or  two  hot  baths,  followed  by 
abundant  perspiration. 

(c)  To  administer  small  doses  of  opium  (laudanum,  Batley's  sedative  drops, 
chlorodine,  etc.),  to  stupefy  the  nervous  centres,  and  render  them  less  susceptible 
to  the  toxic  principle  of  the  disease,  apart  from  the  favorable  influence  the 
opium  may  exert  by  means  of  its  action  upon  the  morbid  secretion  of  the  intes- 
tinal mucous  membrane.  In  the  period  of  reaction  the  treatment  should  be 
very  simple.  If  reaction  come  on  gradually,  and  without  much  fever,  the  treat- 
ment should  be  strictly  hygienic  and  dietetic,  and  alimentation  should  be  resumed 
with  great  care  and  prudence.  If,  on  the  contrary,  the  reaction  supervene  sud- 
denly, and  with  high  fever,  an  antipyretic  treatment  should  be  resorted  to,  based 
upon  the  application  of  cold  compresses ;  and  if  the  fever  is  persistently  above 
104°,  the  general  application  of  cold,  such  as  is  recommended  in  infectious  fevers, 
is  indicated.  I  would  again  recommend  milk  as  the  best  aliment,  especially  if 
with  the  fever  there  are  gastric  complications,  such  as  cramp,  pain,  and  vomiting. 

I  have  never  found  medicinal  substances  administered  internally  whose  effects 
could  be  regarded  as  truly  antipyretic. 

In  reactive  periods  there  attaches  great  interest  from  a  clinical  point  of  view 
to  the  persistence  of  the  symptoms  connected  with  the  functions  of  those  organs 
most  affected  during  the  evolution  of  the.disease,  such  as  cardiac  weakness,  epi- 
gastric pain  with  anorexia,  as  well  as  the  persistence  of  a  slightly  cyanotic  color, 
along  with  which  the  patient  experiences  great  feebleness.  In  this  condition,  the 
treatment  furnished  by  rational  therapeutics  is  valuable.  Since  the  choleraic 
poison  no  longer  remains  in  the  system,  and  prevents  the  proper  action  of  the 
drugs  employed,  accordingly,  I  recommend  hypodermic  injections  of  the  salts  of 
caffein  in  cardiac  weakness  ;  the  salts  of  strychnia  for  epigastric  pain,  and  small 
doses,  hypodermically,  of  valerianate  of  quinine,  and  inhalations  of  oxygen  in 
the  condition  of  persistent  sub-cyanosis. 

Intra-Peritoneal  Styptic  and  Sedative  Injection  in  Cholera. 
Dr.  Ben j.  W.  Richardson,  in  the  Asclepiad  for  Jan.  18'85,  among  other 
modes  of  treatment  of  cholera,  suggests  intra-peritoneal  injections.    He  says  : — 


568 


Progress  of  the  Medical  Sciences. 


[April 


I  have  noAv  to  propose  for  the  first  time  a  much  bolder  and  more  radical  method 
of  treatment  by  the  peritoneum. 

In  my  experimental  researches  on  the  synthesis  of  rheumatism,  I  found  that 
dilute  solutions  of  lactic  acid  could  be  introduced  by  the  peritoneum,  without 
creating  any  such  degree  of  local  lesion  as  was  expected.  I  believe,  therefore, 
that  in  extreme  cases  of  cholera  the  peritoneum  might  well  be  used  for  the  direct 
reception  of  astringent  and  sedative  remedies. 

A  water  solution  of  tannin,  made  by  adding  a  scruple  of  tannin  to  a  pint  of 
warm  distilled  water,  with  ten  minims  of  solution  of  opium,  equalling  a  grain  of 
opium,  might  be  injected  into  the  peritoneum  with  the  utmost  safety,  and,  I 
think,  with  good  effect.  The  tannin  would  dialyze  rapidly  into  the  intestinal 
canal  through  the  intestinal  membranes,  and  would  exert  an  instant  styptic  action 
by  arresting  the  profuse  secretion ;  while  the  opium,  also  quickly  diffused  and 
absorbed,  would  be  most  valuable  as  a  sedative. 

I  name  tannin  as  the  styptic  in  this  case,  because  of  its  freedom  from  irritating 
properties,  and  because,  in  the  body,  it  is  transformed  ultimately  into  a  perfectly 
harmless  product — grape-sugar — which  would  find  its  exit  from  the  body  by  the 
urine,  unless  it  were  used  up  in  combustion  as  a  hydrocarbon.  This  same  plan 
might  be  used  with  hopeful  results  in  the  last  stages  of  typhoid,  especially  when 
those  stages  are  accompanied  by  profuse  hemorrhage. 

In  the  use  of  the  styptic  solution  the  ordinary  small  hypodermic  needle  could 
be  employed,  the  quantity  of  fluid  wanted  for  injection  being  small,  and  the 
course  of  the  injection  slow.  The  rapidity  of  the  dialysis  from  the  intestinal  sur- 
face into  the  intestinal  canal  would,  I  opine,  safely  prevent  the  action  of  the 
styptic  on  the  blood  in  the  underlying  large  abdominal  veins,  the  only  great  source 
of  danger  from  the  operation. 

Contribution  to  the  Study  of  Laryngo-Typhus. 

Dr.  Paul  Koch,  after  an  exhaustive  study  of  laryngo-typhus,  arrives  at  the 
following  conclusions  :  — 

1.  True  laryngo-typhus  has  an  actual  existence;  it  coincides  always  with  the 
acute  period  of  the  general  disease. 

2.  If  symptoms  of  laryngo-stenosis  are  manifested  during  the  period  of  con- 
valescence from  typhoid  fever,  they  are  an  expression  of  perichondritis,  which  is 
generally  manifested  in  acute  attacks  of  the  disease  of  long  duration. 

3.  Operation  is  indicated  as  soon  as  the  symptoms  of  laryngo-stenosis  become 
persistent. 

4.  It  is  always  necessary  in  performing  deep  tracheotomy  to  avoid  the  cricoidal 
region. 

5.  It  is  necessary  to  abandon  the  perichondrial  and  peri-laryngeal  inflamma- 
tions to  their  natural  course,  which  is  very  long,  and  not  to  attempt  to  hasten 
their  cure. 

6.  If  after  recovery  the  patient  is  unable  to  pass  a  canula,  two  methods  of, 
treatment  by  mechanical  resources  remain,  and,  as  a  last  resort,  resection  of  the 
larynx  may  be  performed. — Revue  Mensuelle  de  Laryngolor/ie  d'Otologie  et  de 
Rhinologie,  Feb.  1885. 

Carbolic  Acid  in  Typhoid  Fever. 

In  the  February  number  of  the  Archives  Generates  de  Me'decine  of  the  present 
year,  Dr.  Albert  Robin  strongly  urges  against  the  use  of  carbolic  acid  in  the 
treatment  of  typhoid  fever. 


1885.] 


Medicine. 


5G9 


The  conclusions  reached  by  Dr.  Robin  in  his  paper  are  the  following  :  First 
he  maintains  that  the  administration  of  carbolic  acid  frequently  produces  the 
following  unfavorable  manifestations  :  — 

1.  Nervous  symptoms,  such  as  ataxic  phenomena,  convulsions,  chills,  and 
trembling. 

2   Pulmonary  complications. 

3.  Nausea,  vomiting,  and  colic. 

4.  Profuse  perspiration,  which  not  being  critical  is  useless  or  dangerous. 

5.  Symptoms  of  more  profound  intoxication,  frequency,  smallness,  and  com- 
pressibility of  the  pulse,  cyanosis  of  the  extremities,  collapse,  and  sudden  death. 

6.  Secondary  effects,  evinced  by  cachexia,  anaemia,  and  cirrhosis.  (Pamonet 
Gerardin.) 

These  effects,  according  to  Dr.  Robin,  are  directly  due  to  the  drug,  and  he 
maintains  that  the  carbolic  acid  continuously  employed  in  full  doses  exercises  a 
deleterious  effect  upon  the  chemical  composition  of  the  liquids  and  tissues  of  the 
body  by  removing  from  them  elements  in  the  highest  degree  important. 

Concerning  this  chemical  action  Dr.  Robin  draws  the  three  following  conclu- 
sions : — 

1.  Typhoid  fever  produces  and  eliminates  more  carbolic  acid,  sulphuric  acid, 
and  potassium  than  any  individual,  however  well  and  adequately  nourished. 

2.  The  loss  of  sulphuric  acid  and  of  potassium  being  insufficiently  compensated 
for  by  the  nutriment  consumed  by  the  patient,  the  result  is  that  the  organism  is 
the  more  impoverished  of  these  elements,  the  longer  the  disease  persists. 

3.  This  impoverishment  is  caused  by  a  process  incident  to  the  disease,  and 
should  be  properly  considered  as  one  of  the  causes  of  malnutrition  so  frequently 
manifested  during  convalescence  from  this  disease. 

What,  then,  Dr.  Robin  asks,  in  view  of  these  facts,  results  if,  during  the  course 
of  the  fever,  considerable  quantities  of  carbolic  acid  are  introduced  into  the 
system  ? 

To  this  question,  the  writer  replies  by  advancing  clinical  facts  carefully  observed 
in  proof  of  his  views,  as  follows. 

The  tendency  to  impoverish  the  organism  of  sulphur  and  potassium,  which  is 
considerably  increased  during  the  typhoid  condition  by  the  administration  of  car- 
bolic acid,  may  be  estimated  at  an  additional  loss  of  more  than  7  grains  of  sul- 
phuric acid  and  more  than  3  grains  of  potassium  for  every  gramme  of  carbolic 
acid  taken  by  the  patient.  The  entire  daily  loss,  accordingly,  for  a  patient  of 
average  weight  to  whom  a  maximum  amount  of  the  acid  has  been  administered, 
would  amount  to  nearly  100  grains  of  sulphuric  acid  and  40  of  potassium.  On 
the  strength  of  these  data,  M.  Robin  proscribes  carbolic  acid  from  the  list  of 
remedies  for  typhoid  fever,  as  also  all  other  organic  substances  which  are  elimi- 
nated in  the  same  manner. — Revue  Medicate,  Feb.  14,  1885. 

A  Case  of  Acute  Rheumatic  Polyarthritis  in  a  Child  thirteen  weeks  old. 

An  interesting  and  unusual  case  of  rheumatism  in  a  child  thirteen  weeks  old 
is  reported  in  Prag.  Med.  Wochenschrift,  1884,  p.  410  :  — 

The  child  in  the  second  month  presented  symptoms  of  beginning  rachitis.  It 
became  ill  when  twelve  weeks  old,  and  a  swelling  of  the  right  shoulder-joint  with 
pain  and  redness  was  manifested.  On  the  fifth  day  of  illness,  after  a  gradual  and 
regular  elevation  of  the  temperature  to  102.2°  F.,  the  ankle-joint  was  attacked  ;  on 
the  sixth  day,  the  left  knee-joint ;  on  the  ninth,  with  a  temperature  of  101.8°  F., 
the  right  elbow-joint.  On  the  twentieth  day  motion  in  all  the  joints  was  possible. 
Death  occurred  on  the  thirty-fourth  day  from  a  right-sided  pleuro-pneumonia. 


570 


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[April 


Post-mortem  examination,  in  the  absence  of  either  traumatic  origin  of  the 
disease,  tubercular  or  syphilitic  diathesis,  confirmed  the  clinical  diagnosis. — Cen- 
tralblattfur  Klin.  Med.,  Feb.  7,  1885. 

Pulmonary  Manifestation  in  Rheumatism. 

M.  Lebreton,  in  a  thesis  lately  published,  gives  a  clear  and  erudite  exposi- 
tion of  the  pulmonary  symptoms  frequently  manifested  in  rheumatism  and  arthritis. 
Such  manifestations  generally  precede  the  local  appearance  of  the  disease  by  a 
few  days,  and  rarely  also  are  isolated  and  unique,  forming  the  only  phase  of  the 
attack.  They  may  also  occur  without  implication  of  the  heart.  The  writer  holds 
that  the  term  "  rheumatic  pneumonia"  should  be  abandoned  as  a  misnomer,  inas- 
much as  there  is  never  present  a  true  pneumonia.  The  affection  presents  many 
characteristic  features ;  the  face  of  the  patient,  instead  of  being  flushed  and  red, 
is  pale,  the  body  is  bathed  in  acid  sweat,  and  the  stethoscopic  symptoms  are 
fugacious  and  variable.  The  disease  is  ordinarily  not  dangerous,  but  may  return 
frequently.  Besides  the  pneumonic  form  there  is  also  an  oedematous  variety 
which  may  have  slow  progress  with  dyspnoea,  distressing  cough,  and  abundant 
expectoration,  or  be  fulminant  in  its  nature.  The  arthritic  manifestations  of 
the  disease  are  characterized  by  haemoptysis  and  remittent  attacks — a  true  pul- 
monary gout — of  which  the  crises  are  habitually  nocturnal  and  associated  at  first 
with  a  dry  cough,  followed  afterwards  by  stringy  and  frothy  expectoration  and 
considerable  nasal  discharge.  During  the  day  the  patient  is  entirely  free  from 
all  discomfort,  but  at  night  the  attacks  return  to  disappear  as  suddenly  as  they 
began.  The  "arthritic  bruit,"  M.  Lebreton  considers,  with  Woillez  and 
Hnchard,  to  be  rather  a  congestion  than  a  pleural  friction. — Gazette  Medicale 
de  Paris,  Jan.  17,  1885. 

The  Therapeutic  Value  of  Iodoform  in  the  Treatment  of  Gout. 

Dr.  Testa,  after  extended  experimental  investigation  and  clinical  observation 
upon  the  effect  of  iodoform  in  gout,  arrives  at  the  following  conclusions  as  to  its 
physiological  effects  and  as  to  its  value  in  the  treatment  of  this  disease. 

1.  Iodoform  augments  the  dairy  quantity  of  urea  eliminated  with  the  urine,  and 
thus  increases  the  amount  of  organic  change  by  hastening  the  process  of  oxida- 
tion. 

2.  It  diminishes  the  daily  quantity  of  uric  acid,  which  by  excessive  nitrogenous 
diet  is  passed  with  the  urine,  because  by  hastening  the  process  of  oxidation  it  does 
not  facilitate  the  metamorphosis  into  urea. 

3.  It  diminishes  oxaluria  dependent  upon  the  introduction  of  aliments  rich  in 
oxalic  acid,  because,  owing  to  the  increased  oxidation,  this  acid  is  changed  to 
carbon  dioxide  and  water. 

4.  In  gout  it  diminishes  the  quantity  of  uric  acid  in  the  blood  by  increasing 
oxidation  in  the  economy. 

5.  Iodoform  is  a  rational  remedy  for  gout,  because,  by  removing  the  uric  acid 
from  the  blood,  it  fulfils  the  conditions  necessary  for  the  cure  of  the  disease. 

The  conclusions  reached  from  clinical  experience  in  the  use  of  the  drug  are  as 
follows  :  — 

1 .  Iodoform  has  generally  a  very  beneficial  effect  upon  gout,  reducing  the 
number  of  the  attacks  and  diminishing  both  their  intensity  and  duration. 

2.  In  cases  where  gout  is  complicated  with  renal  disease,  caution  is  necessary 
in  its  administration,  since,  if  its  elimination  is  more  or  less  retarded,  or  prevented, 
an  unfavorable  cumulative  effect  may  result. 


1885.] 


Medicine. 


571 


3.  In  kidney  disease,  therefore,  the  drug  must  be  carefully  administered  or 
entirely  discarded  according  to  the  extent  of  the  renal  lesion. 

Apropos  of  the  foregoing  conclusions,  Dr.  Testa  suggests  the  following  points 
for  the.  consideration  of  other  observers  :  — 

1.  Whether  in  some  cases  iodoform  may  effect  a  radical  cure  of  gout. 

2.  Whether,  and  to  what  extent,  it  may  be  used  to  resolve  deposits  in  the 
joints,  due  to  gouty  diathesis. 

3.  The  determination  of  the  nature  and  extent  of  renal  disease  which  contrain- 
dicate  its  use. 

4.  The  study  of  the  simultaneous  and  successive  effect  of  the  stigmata  of  maize 
and  of  iodoform,  in  order  to  arrive  at  a  definite  conclusion,  whether  the  two 
remedies  combined,  by  modifying  the  catarrhal  condition  of  the  kidneys,  are 
rendered  more  tolerable  than  the  iodoform  alone. — Gazetta  Medico,  di  Torino, 
Feb.  15.  1885. 

Persistent  Hiccough  cured  by  Jaborandi. 

Dr.  Pagenstecher  reports  a  case  of  persistent  hiccough  cured  in  six  days 
by  a  decoction  of  jaborandi  after  all  other  remedies  had  failed  to  exert  any  effect. 
The  intervals  between  the  attacks  gradually  became  less,  the  contractions  of  the 
diaphragm  varied  from  sixteen  to  twenty,  to  thirty  and  forty  per  minute.  The 
pulse  was  very  variable,  ranging  from  100  to  120  to  60  or  70.  Respiration  was 
frequent,  averaging  about  24  per  minute.  The  patient  was  haggard,  and  during 
the  last  three  days  had  not  eaten  for  fear  of  vomiting. 

During  the  progress  of  the  disease,  no  remedy  exerted  any  influence  whatever. 
Finally  faradization  was  tried  and  seemed  at  first  to  give  good  results.  Improve- 
ment was,  however,  but  temporary,  and  the  hiccough  became  worse.  As  a  last 
resort  jaborandi  was  tried.  A  decoction  of  the  leaves  was  made,  and  its  ad- 
ministration was  followed  by  its  prompt  therapeutic  action.  Perspiration  con- 
tinued about  two  hours,  and  at  the  end  of  that  time  the  hiccough  disappeared. 

The  therapeutic  action  of  the  drug  is  explained  by  Dr.  Pagenstecher,  by  sup- 
posing that  perspiration  produced  a  molecular  transformation  in  the  phrenic 
nerve  and  the  tissues  adjacent,  which  enabled  the  nerve  to  resume  its  normal 
function. — Bulletin  G6n6ral  de  Th<£rapeutique,  Jan.  30,  1885. 

Inoculation  of  Tuberculosis  in  a  Woman. 

E.  A.  Tscherning  (Hospitals-Tidende,  December  17,  1884)  records  the 
following  interesting  case,  which  has  a  valuable  bearing  on  the  theory  of  inocu- 
lation of  tuberculosis. 

Maria  P.,  ast.  24,  cook,  in  the  service  of  the  late  Professor  H.,  who  died  at 
the  end  of  July,  1884,  of  florid  pulmonary  phthisis,  from  which  he  had  been  suf- 
fering for  five  or  six  months.  His  expectoration  was,  toward  the  end  of  his  life, 
an  almost  pure  culture  of  tubercle  bacilli  in  pus.  The  girl  was  perfectly  healthy 
and  strong,  had  never  suffered  in  any  way  from  scrofulous  or  tuberculous  diseases, 
and  had  no  hereditary  disposition  to  tuberculosis.  A  few  days  before  the  death 
of  Professor  H.,  the  girl,  pricking  herself  with  a  piece  of  glass  from  a  broken 
cuspidor  which  he  had  used,  inflicted  a  small  wound  on  the  volar  surface  of  the 
first  phalanx  of  the  left  middle  finger. 

A  fortnight  later,  she  presented  herself  before  Dr.  Tscherning  with  a  begin- 
ning panaritium.  After  the  application  of  compresses  with  a  solution  of  carbolic 
acid  the  symptoms  abated  somewhat.  There  occurred  no  suppuration,  but  in  the 
subcutaneous  areolar  tissue  was  felt  a  small  lump  scarcely  of  the  size  of  a  split 
pea,  which  remained  stationary  for  several  weeks,  accompanied  by  oedema  and 


572 


Progress  of  the  Medical  Sciences. 


[April 


moderate  soreness  of  the  surrounding-  tissue.  A  small  incision  was  made  at  the 
end  of  August,  and  the  small  lump  composed  of  granulations  between  the  sheath 
of  the  tendon  and  the  skin  was  scraped  out.  The  wound  healed  by  the  first 
intention  under  a  dressing  of  iodoform  and  corrosive  sublimate,  and  the  patient 
improved  provisionally. 

In  the  beginning  of  October,  she  complained  of  pains  on  flexion  of  the  fingers. 
The  skin  and  the  subcutaneous  tissue  of  the  phalanx  and  the  adjacent  part  of  the 
vola  of  the  hand  were  slightly  swollen.  No  distinctly  limited  swelling  of  the 
sheath  of  the  tendon  could  be  felt.  The  patient  used  local  steam  baths  for  a  few 
weeks,  and  when  she  called  again,  in  the  middle  cf  October,  a  distinct  thickening 
of  the  sheath  of  the  tendon  could  be  felt.  The  mobility  of  the  finger  was  dimin- 
ished, and  it  was  the  seat  of  moderate  pain  and  sensitiveness.  At  the  same  time 
there  were  found  two  swollen  glands  at  the  elbow  and  two  in  the  axilla  of  the 
same  side.  Otherwise  she  was  perfectly  well,  and  especially  showed  no  trace  of 
pulmonary  symptoms. 

On  the  21st  of  November  the  swollen  glands  were  extirpated,  the  finger  was 
exarticulated  at  the  metacarpo-phalangeal  joint,  the  palmar  skin  was  slit  open, 
the  tendon  with  its  swollen  sheath  was  removed  up  to  the  middle  of  the  hollow 
of  the  hand,  and  the  subcutaneous  granulations  present  were  cut  out  with  scissors 
or  scraped  out  with  a  curette.  The  operation  was  performed  by  Professor  Studs- 
gaard  with  a  1  :  1000  solution  of  corrosive  sublimate  for  antiseptic,  and  the  wound 
was  dressed  with  gauze  impregnated  with  the  same  substance.  It  healed  by  the 
first  intention  in  eleven  days. 

The  pathological  changes  found  were  as  follows :  The  sheath  of  the  tendon 
was  closed  with  pale  granulations.  The  serous  cover  of  the  tendon  was  studded 
with  petechise.  No  pus,  cheesy  masses,  articular  or  bone  affection  were  found. 
Under  the  microscope,  the  granulations,  after  hardening  in  alcohol  and  staining 
with  picrocarmine,  showed  very  numerous  elementary  tubercles,  sometimes  with 
cheesy  degeneration  of  the  centre,  numerous  large  cells,  and  beautiful  partly 
central  giant-cells.  The  extirpated  glands  looked  to  the  naked  eye  like  common 
hyperplastic  glands  without  pus  or  cheesy  substance.  The  microscope  revealed 
hyperplasia  due  to  large  cells  with  interspersed  elementary  tubercles.  In  all  the 
sections,  both  of  the  granulations  on  the  sheath  of  the  tendon  and  of  the  lym- 
phatic glands,  were  found  distinct  tubercle  bacilli  demonstrable  by  means  of 
Chelich's  staining  method.  They  were  partly  imbedded  in  epithelioid  cells  or 
giant-cells,  partly  situated  at  the  confines  of  the  microscopical  necrobiotic  spots. 
Most  frequently  they  were  isolated,  but  here  and  there  two  or  even  three  were 
found  together  forming  a  more  or  less  open  V-    Often  they  contained  spores. 

The  author  adds  that  these  conditions  correspond  entirely  with  what  he  has 
found  in  about  thirty  cases  of  local  tuberculosis  (arthritis,  tenositis,  spondylitis, 
pyogenic  membranes,  lymphatic  glands,  testicles,  tongue,  pyelonephritis). 

Spontaneous  Peritonitis. 

In  an  interesting  paper  in  the  Deutsche  Med.  Wochenschr.,  1884,  No.  17,  Prof. 
E.  Leyden  remarks  that  the  occurrence  of  idiopathic  peritonitis,  though  very 
problematic,  has  so  far  been  demonstrated  by  post-mortem  observations,  especially 
in  Germany,  that  the  text-books  now  speak  with  great  caution  on  this  matter. 
The  study  of  the  literature  of  the  subject  affords  reason  to  believe  that  the 
appearance  of  peritonitis  of  a  spontaneous  origin  is  not  so  rare  as  has  been  sup- 
posed. Leyden  has  himself  had  under  observation  "  three  cases  in  which  there 
was  no  possibility  of  a  mistake  in  diagnosis." 


1885.] 


Medicine. 


573 


Spontaneous  peritonitis  appears  more  frequently  in  women  than  in  men,  and 
seems  to  be  coincident  with  certain  mal-conditions  of  menstruation  arising  in  cold 
and  in  inflammation  of  the  colon.  The  nature  of  the  disease  points  to  an  infectious 
origin  through  micro-parasites,  but  microscopic  examination  does  not  always 
reveal  them  in  the  same  form.  The  question  then  arises  whether  peritonitis  may 
not  be  treated  by  operative  procedure.  The  difficulty  here  lies  in  the  washing 
out  of  the  peritoneal  cavity,  and  in  seasonable  diagnosis.  Exploratory  puncture, 
which  in  other  cases  is  so  valuable  as  an  aid  to  diagnosis,  is  here  unreliable,  since 
as  a  rule  there  is  not  a  very  abundant  exudation,  and  the  meteorism  coexisting 
renders  it  much  more  difficult  to  obtain  fluid  for  examination. 

Simon,  P.  Gdttmann  Litten,  Landau,  and  Israel  further  discuss  the  sub- 
ject from  the  same  standpoint  as  Leyden.  The  first  three  produce  data  from  their 
experience,  which  renders  the  spontaneous  origin  of  peritonitis  probable.  Lan- 
dan  gives  as  his  conviction  that  the  infection  is  from  without,  and  that  it  is  often 
difficult  to  find  after  death  the  location  where  infection  took  place.  In  this 
light  he  considers  that  a  spot  of  ulceration  and  perforation  in  the  vermiform  pro- 
cess, which  has  healed,  simply  erosion  of  the  mucous  membrane  of  the  colon, 
which  can,  in  a  short  time,  not  be  detected ;  and  also  the  transference  of  gonor- 
rheal inflammation  along  the  Fallopian  tubes,  or  through  the  uterine  lymphatics. 
Landau  holds  that  in  operative  treatment  of  peritonitis  an  incision  should  be 
made,  and  the  full  benefit  of  thorough  rinsing  and  drainage  of  the  peritoneal 
cavity  be  thus  obtained. 

Israel  also  thinks  the  operative  treatment  by  incision  advisable,  and  cites  two 
cases  in  which  he  successfully  practised  this  method.  In  one  he  operated  by 
incision  and  thorough  washing  of  the  peritoneal  cavity ;  in  the  other  he  punc- 
tured Douglas's  cul-de-sac. — Centralbl.  fur  Chirurgie,  Dec.  20,  1884. 

Nephritis  and  Uterine  Epithelioma. 
Dr.  E.  Lanceraux  bases  an  article  on  the  renal  complications  of  epithelioma 
of  the  uterus  in  twenty-three  cases.  The  first  part  of  his  paper  is  a  report  of  the 
cases.  He  then  gives  a  clinical  description  of  epithelioma  of  the  uterus,  the  only 
one  of  the  carcinomatous  affections  of  the  uterus  which  he  desires  to  consider, 
since  it  is  the  only  one  which  presents  a  certain  degree  of  curability.  Further- 
more, the  seat  of  predilection  of  epithelioma  at  the  beginning,  as  well  as  its  man- 
ner of  spreading,  marks  out  the  course  to  be  pursued  by  the  surgeon ;  when 
limited  to  the  cervix,  and  no  complication  exists,  intervention  must  be  as  prompt 
as  possible. 

It  was  seen,  in  a  recent  discussion  on  cancer  of  the  uterus  in  the  Societe  de 
Chirurgie,  that  the  preceding  proposition,  formulated  by  Lanceraux,  is  identical 
with  the  opinion  of  the  great  majority  of  French  surgeons.  It  is  a  general  rule, 
applicable  to  carcinomata  of  the  uterus  as  well  as  to  those  in  other  places.  Gal- 
lard  holds  that  they  should  be  extirpated  whenever  there  is  even  a  hope  that  the 
whole  of  the  diseased  part  may  be  removed  ;  and  on  this  point  it  seems  to  him 
that  there  should  be  no  hesitation  on  account  of  fear  of  return. 

It  is  Lanceraux' s  opinion  that  the  vaginal  cul-de-sac,  and  perhaps  more  often 
the  lips  of  the  os,  which  is  the  point  of  departure  of  the  epithelioma.  The  pro- 
gress of  the  neoplasm  implies  a  double  action :  the  process  of  development,  and 
that  of  ulceration,  the  first  tending  to  the  progressive  extension  of  the  disease,  the 
second  to  the  destruction  of  the  tissues  and  to  serious  complications  to  be  enume- 
rated later.  In  a  word,  epithelioma  is  represented,  at  the  beginning,  by  a  pro- 
duction in  relief,  a  sort  of  mammilated  vegetation,  which  is  extended  by  the 
multiplication  and  infiltration  into  the  neighboring  epithelioid  cells  (epidermic 
No.  CLXXVIIL— April,  1885.  37 


574 


Progress  of  the  Medical  Sciences. 


[April 


globes),  which  represent  the  fundamental  element.  At  the  same  time,  the  parts 
first  attacked  undergo  regressive  metamorphoses,  whence  results  a  more  or  less 
extensive  ulcer,  always  circumscribed  by  an  inverted  edge,  markedly  hardened 
and  very  characteristic.  The  functional  disorders  accompanying  this  morbid 
evolution  are  numerous.  First  among  these  are  the  hemorrhages,  shown  at  the 
beginning  only  by  a  menorrhagia,  but  which,  later,  become  so  abundant  as  to 
constitute  metrorrhagia,  and  are  successively  complicated  by  white,  mucous, 
reddish,  bloody,  and  very  fetid  discharges.  Digestive  troubles  then  appear, 
impairing  the  general  nutrition  of  the  patient. 

In  regard  to  the  disorders  of  the  urinary  organs,  says  Lanceraux,  the  urine 
becomes  bloody  as  soon  as  the  vegetation  invades  the  base  of  the  bladder ;  later, 
when  the  vegetation  becomes  ulcerated,  and  especially  when  there  is  retention  ot 
urine,  it  becomes  purulent.  Then,  when  there  is  obstruction  of  the  ureters  only 
at  their  outlets,  the  urine  becomes  pale,  and  the  specific  gravity  is  lowered ;  and 
the  solid  matters  are  reduced.  In  many  cases,  also,  albumen  is  found  in  the 
urine.  From  a  clinical  point  of  view  these  urinary  troubles  are  almost  con- 
stantly complicated  by  arffiiuic  accidents;  uraemia  of  the  digestive  apparatus, 
so  to  speak,  cerebral  urasmia,  respiratory  or  dyspnceic  uraemia,  more  rare  than  the 
preceding  forms.  This  symptom,  ordinarily  accompanied  by  a  reduction  of  the 
-temperature  by  one  or  two  degrees,  is  usually  the  cause  of  death,  unless  this 
takes  place  prematurely  from  some  special  complication,  as  hemorrhage,  perito- 
nitis, etc.  It  always  occurs  in  an  advanced  stage  of  the  disease,  and  should  be 
considered  a  symptom  of  serious  importance. 

As  regards  the  lesions  observed,  Lanceraux  classes  them  as  primary,  secondary, 
and  tertiary  :  the  first  are  situated  in  the  uterus,  vagina,  and  the  corresponding 
lymphatic  glands  ;  the  second  proceed  from  the  first,  principally  from  the  exten- 
sion of  the  disease  to  the  bladder  and  the  ureters,  and  especially  affecting  the 
pelves  of  the  kidneys.  The  third  class  consist  of  various  modifications  of  the 
digestive  tract  and  of  the  heart. 

Lanceraux  explains  the  progress  of  the  carcinomatous  affection  on  anatomical 
grounds.  It  is,  so  to  speak,  regulated  by  the  intimate  connections  between  the 
genito-urinary  organs.  The  upper  portion  of  the  cervix  uteri  and  that  of  the 
vagina  are  connected  with  the  base  of  the  bladder  by  dense  cellular  tissue. 
What  is  more  natural,  then,  than  the  extension  of  the  neoplasm  to  the  bladder? 
This  extension  takes  place  through  the  intermediation  of  the  epithelial  tracts  con- 
ducing to  the  formation  of  embryonal  connective  tissue  in  the  midst  of  the  com 
pact  tissue  uniting  the  vagina,  uterus,  and  bladder.  The  morbid  process  extends 
to  the  ureters,  slowly  causing  contraction,  from  which  there  is  a  natural  succes- 
sion of  accidents  :  stricture  of  the  ureters,  consecutive  dilatation  of  these  tubes, 
which  attain  the  size  of  the  small  intestine,  distension  of  the  pelves  and  calices, 
and  atrophy  of  the  papillary  extremities  of  the  pyramids  of  Malpighi. 

The  renal  lesions  are  subordinate  to  the  duration  of  the  utero-vesical  lesion. 
They  consist  in  more  or  less  marked  cirrhosis,  but  this  must  be  differentiated 
from  primary  interstitial  nephritis  by  the  state  of  the  free  surface  of  the  organ, 
which  is  brilliant,  yellow,  and  smooth  :  from  saturnine  arterial  nephritis,  in 
which  the  free  surface  of  the  kidney  is  granular,  and  in  which  the  pelves  and 
calices  are  never  dilated,  nor  the  Malpighian  pyramids  effaced.  The  histological 
lesions  are  also  those  of  diffuse  cirrhosis,  especially  marked  at  the  seat  of  the 
Malpighian  pyramids.  The  process  extends  to  the  cortical  substance,  at  the 
level  of  which  the  different  lobules  are  limited  by  fibrous  rings.  In  the  excretory 
canals  the  epithelium  is  clouded,  and  forms  refracting  particles,  modifications 
which  exist  in  a  high  degree  in  the  collecting  tubes  of  the  pyramids,  and  to  a  less 
extent  in  the  convoluted  tubes.    Marked  histological  alterations  are  also  seen  in 


1885.] 


Medicine. 


.  575 


the  digestive  organs.  The  stomach  is  retracted,  the  mucous  membrane  thrown 
into  folds  and  more  or  less  injected,  disseminated  sclerosis  is  present,  and  the 
mucous  membrane  is  covered  with  a  viscid  and  very  adherent  mucus.  The  small 
intestine  is  also  lined  with  a  thick  layer  of  mucus,  but  the  mucous  membrane  is 
pale  and  discolored ;  that  of  the  large  intestine  is  slate-colored  in  places,  more 
rarely  ulcerated  or  surmounted  by  small  furuncular  nodules. 

Lanceraux  concludes  that  in  interstitial  nephritis  or  primitive  sclerosis,  hyper- 
trophy of  the  heart  is  forcibly  under  the  immediate  dependence  of  the  alteration 
of  the  arterial  system,  and  not,  as  a  certain  number  of  authors  think,  subordi- 
nated to  the  renal  lesion. — Annales  de  Gynecologies  October,  1884. 

Occlusion  of  both  Ureters  by  Renal  Calculi.    Anuria  for  lioenty-three 
Consecutive  Days. 

Dr.  Ernst  Bischoff  publishes  the  following  remarkable  case,  which  was 
under  his  care,  in  connection  with  Prof,  von  Ziemssen. 

The  patient  was  a  man  58  years  old,  who  for  14  years  had  suffered  from  gout 
and  lithiasis.  He  had  collected  in  the  course  of  this  time  a  great  number  of  renal 
calculi  of  various  sizes  which  had  passed  with  comparatively  little  pain.  About 
the  end  of  September,  1883,  he  became  ill,  and  severe  pain  developed  in  the 
region  of  the  left  kidney.  This  in  a  few  days  moderated,  but  did  not  entirely 
disappear.    The  urine  in  the  mean  while  was  bloody  at  intervals. 

This  condition  persisted  for  two  weeks,  when  the  patient  was  compelled  by  the 
advent  of  fever  and  consequent  debility  to  remain  constantly  at  home.  About  the 
middle  of  October  phlebitis  of  the  saphenous  vein  in  the  left  leg  appeared,  and 
finally  extended  to  the  thigh,  thus  involving  the  whole  extremity.  All  this  time 
he  suffered  much  pain  in  the  region  of  the  left  kidney,  and  his  urine  was  spar- 
ingly voided,  frequently  contained  blood,  and  always  albumen.  At  the  end  of 
October  he  was  entirely  convalescent,  and  by  the  end  of  November  was  able  to 
attend  to  his  business. 

On  Jan.  25th,  1884,  he  passed,  while  urinating,  a  calculus  somewhat  larger  than 
a  pea  without  difficulty.  On  Friday,  April  25th,  the  patient  took  a  long  walk, 
and  on  his  return  home,  five  hours  after,  on  attempting  to  urinate  passed  an  enor- 
mous quantity  of  blood,  without,  however,  suffering  any  immediate  inconvenience 
therefrom.  Shortly  the  pain  in  the  neighborhood  of  the  left  kidney  returned, 
but  passed  away  during  the  night ;  in  the  morning  he  was  able  to  go  to  his  office, 
his  appetite  during  the  day  being  excellent.  In  the  evening  of  January  26th, 
his  pain  returned,  and  at  this  time  Dr.  Bischoff  was  called  to  see  the  patient. 
His  condition  was  generally  favorable,  the  heart  slightly  enlarged,  its  impulse 
weakened.  The  patient  was  a  moderate  beer-drinker,  and  the  condition  of  the 
organ  was  diagnosed  as  one  of  fatty  degeneration.  Examination  revealed  pain 
increased  by  pressure  over  the  left  kidney,  and  considerable  swelling  in  this  region 
was  also  manifest.  No  urine  had  been  passed  the  whole  day.  Moist  applica- 
tion to  the  swollen  parts  and  appropriate  drinks  had  a  favorable  effect,  and  the 
following  morning  at  7  A.  M.  about  one-half  pint  of  urine  was  passed.  Exami- 
nation showed  the  presence  of  albumen. 

Jan.  28th.  The  patient  went  to  his  office,  having  but  little  pain.  No  urine  was 
passed  the  whole  day,  and  on  examination  with  a  catheter  the  bladder  was  found 
empty. 

29th  and  30th.  No  urine  was  passed,  condition  of  patient  otherwise  good. 
Diagnosis  was  accordingly  made  of  occlusion  of  both  ureters,  and  appropriate 
treatment  by  diaphoretics  and  diuretics  instituted,  and  continued  from  this  time 
on. 


576. 


Progress  of  the  Medical  Sciences. 


[April 


May  1.  Condition  of  patient  favorable,  but  anuria  persisted. 
2d.  Less  than  a  cubic  inch  of  urine  passed,  very  dark  and  bloody.    A  hot  bath 
of  99 j°  F.,  followed  by  the  dry  pack,  was  given. 
3d  and  4th.  Same  treatment. 

On  the  evening  of  the  4th,  slight  oedema  of  the  joints  was  noticed.  No  urine 
voided,  bladder  empty. 

oth.  There  appeared  a  troublesome  abdominal  tension,  which  passed  away  after 
some  evacuation  of  the  bowels. 

6th  to  10th.  Condition  of  the  patient  unchanged.  Appetite  good,  but  eating 
was  followed  by  persistent  hiccough.    No  urine  passed. 

The  night  of  November  10th,  fever  suddenly  developed,  and  with  it  severe 
stomatitis,  which  prevented  the  patient  partaking  of  food.  (Edema  also  appeared 
in  the  legs  and  gradually  extended  to  the  abdomen.  General  condition  of  the 
patient  better. 

loth.  Pain  again  suddenly  returned  in  the  region  of  the  left  kidney,  and  the 
patient  was  dull,  ate  little,  and  frequently  was  inclined  to  vomit. 

16th.  While  at  stool  patient  passed  a  little  less  than  a  gill  of  urine,  which  was 
bloody,  acid  in  reaction,  and  of  normal  odor.  Pain  still  persisted,  the  patient 
was  apathetic,  had  no  appetite,  was  very  thirsty,  and  the  tongue  dry.  Much  in- 
clination to  vomit. 

17t?i.  Pulse  between  104  and  102.  Temperature  of  the  skin  very  high. 
Urine  still  suppressed.  Patient  apathetic,  somnolent,  and  gradually  becoming 
unable  to  converse. 

18*7*.  Patient  restless,  and  delirious  ;  pulse  irregular.  (Edema  had  increased, 
and  pain  over  both  kidneys  considerable. 

19th.  Respiration  difficult  from  collection  of  mucus  in  the  trachea.  The  pa- 
tient, though  somnolent,  could  be  roused,  and  would  then  answer  correctly,  if 
questioned.  Grew  worse  during  the  day,  and  died  at  4  P.  M.,  comparatively 
easily.  At  no  time  was  urea  detected  in  the  secretion  of  the  skin,  though  it  was 
daily  sought  for,  neither  at  any  time  were  convulsions  observed. 

The  post-mortem,  held  May  20th,  showed  the  presence  in  each  ureter  of  a  renal 
calculus. 

That  in  the  right  ureter  was  about  3  inches  from  the  pelvis  of  the  kidney 
firmly  impacted,  about  1  inch  in  length,  and  f  of  an  inch  in  diameter  at  its 
greatest  circumference.  The  remaining  portion  of  the  urethra  was  normal.  The 
kidney  itself  was  much  contracted  and  the  pelvis  dilated.  The  left  kidney  had 
undergone  compensatory  hypertrophy  and  showed  the  existence  of  suppurative 
nephritis.  The  pelvis  was  dilated  and  contained  a  bloody  fluid  and  some  small 
calculi. 

The  ureter  at  its  commencement  was  greatly  dilated  for  nearly  4  inches;  at  the 
end  of  this  dilatation  a  collection  of  small  calculi  ten  or  twelve  in  number  was 
found  in  the  ureter,  which  was  slightly  inflamed.  About  one-half  inch  further  on, 
a  calculus,  the  size  of  a  large  bean,  completely  occluded  the  ureter.  The  remain- 
ing portion  of  the  ureter  empty  and  normal. 

The  bladder  itself  was  contracted,  and  contained  only  a  few  drops  of  dark- 
colored  urine. 

As  far  as  is  known,  this  case  is  without  precedent,  the  absence  of  uraemia  and 
convulsions  being  very  remarkable.  In  cases  hitherto  observed  the  prolongation 
of  life  beyond  ten  days,  during  complete  anuria,  is  extremely  rare. 

The  bibliography  of  the  subject  is  appended  and  further  confirms  the  unique 
character  of  the  history  recorded. — Deutsches  Archiv  fur  Klin.  Med.,  December, 
1884. 


1885.] 


Surgery. 


577 


SURGERY 

Cancer  of  the  Tongue. 

At  a  meeting  of  the  Medical  Society  of  London  Mr.  F.  Boweeman  Jessett 
read  a  paper  on  cancer  of  the  tongue,  with  especial  reference  to  the  frequency 
with  which  the  disease  attacks  this  organ,  its  etiology  and  treatment.  Of  2227 
cases  seen  at  the  Cancer  Hospital,  the  tongue  was  the  seat  of  the  disease  in  1 90 
cases,  or  about  8.5  percent.  Statistics  collected  by  Sir  James  Paget,  Mr.  Sibley, 
von  Winiwarter,  and  Mr.  Barker  were  given  and  compared,  and  there  was  a 
general  agreement  in  the  results  arrived  at.  Mr.  Barker's  statistics  showed  a 
higher  percentage  of  cases  of  cancer  of  the  tongue  (16.3  per  cent.),  and  this 
high  rate  might  have  been  due  to  the  large  number  of  Welsh  miners  admitted  to 
the  University  College  Hospital.  There  was  no  organ  in  the  body  which  is  sub- 
jected to  such  rough  treatment  as  the  tongue,  and  this  fact,  combined  with  the 
surroundings  of  the  organ,  affords  some  explanation  of  the  frequency  with  which 
cancer  occurs  in  the  tongue.  Phthisis,  syphilis,  and  hereditary  tendencies  were 
classed  as  the  constitutional  causes  of  cancer  of  the  tongue.  He  believed  that 
tubercular  ulcers  were  disposed  to  become  cancerous.  He  thought  no  one  would 
deny  the  difficulty  that  frequently  existed  in  diagnosing  between  tubercular, 
syphilitic,  and  cancerous  ulcers  of  the  tongue.  He  strongly  advised  excision  of 
the  tongue  if  treatment  for  a  fortnight  effected  no  benefit.  With  regard  to  the 
relation  of  cancer  with  ichthyosis,  Mr.  Morris  had  so  thoroughly  worked  out  this 
point  that  he  should  not  treat  further  of  it.  Age  had  considerable  influence  on 
the  development  of  the  disease.  The  average  age  in  the  statistics  he  had  collected 
was  fifty-two,  the  youngest  patient  was  thirty-two,  and  the  oldest  seventy-nine. 
Treatment  was  next  considered,  and  as  the  disease  was  regarded  as  not  purely 
local,  he  believed  that  some  day  a  remedy  for  cancer  would  be  found.  Early 
removal  of  the  nodule  was  strongly  insisted  upon,  and  the  incisions  should  go 
wide  of  the  disease.  Division  of  the  gustatory  nerve  and  ligature  of  the  lingual 
artery  were  of  value  in  extreme  cases.  The  various  operations  which  had  been 
practised  for  removal  of  the  tongue,  or  a  portion  of  it,  were  briefly  reviewed. 
The  operation  for  removal  of  the  whole  tongue  was  at  least  two  hundred  years 
old.  Mr.  Barker  had  found  that  in  only  17  out  of  170  cases  had  the  patient 
been  free  from  disease  at  the  end  of  a  year ;  in  639  cases  operated  on  the  death- 
rate  was  20.7  per  cent.  An  examination  of  all  the  published  cases  which  were 
available  had  led  him  to  the  conclusion  that  no  one  operation  yielded  the  best 
result  in  all  cases.  The  death-rate  after  operations  with  the  ecraseur  was  8.5 
per  cent.,  whereas  that  after  the  operation  by  scissors  was  31  per  cent.  The 
ecraseur  was  most  suitable  when  the  anterior  part  of  the  tongue  was  the  seat  of 
the  disease,  and  the  knife  or  scissors  was  the  best  when  the  diseased  area  was 
small.  The  difficulty  of  removing  the  whole  of  the  growth  when  large  by  the 
ecraseur  was  referred  to,  and  a  preference  for  the  operation  by  ligature  of  the 
lingual  artery  and  removal  with  the  scissors  was  expressed.  On  the  whole,  how- 
ever, the  statistics  spoke  strongly  in  favor  of  operation  with  the  ecraseur. 

Mr.  Frederick  Treves  thought  that  more  might  be  said  in  favor  of  Billroth' s 
operation  of  removal  with  the  scissors  preceded  by  deligation  of  the  lingual 
arteries.  The  difference  between  the  effects  of  the  ecraseur  and  the  scissors  was 
the  contrast  between  a  lacerated  and  an  incised  wound,  and  the  contused  state 
left  after  the  action  of  the  ecraseur  was  necessarily  followed  by  some  sloughing. 
Salivation  probably  had  a  good  deal  to  do  with  the  foulness  of  the  discharge  from 
the  mouth  ;  he  therefore  recommended  the  excision  of  a  short  portion  of  the 
gustatory  nerve.    With  the  necessary  precautions,  he  thought  that  Billroth' s 


578 


Progress  of  the  Medical  Sciences. 


[April 


operation  was  the  one  which  could  be  carried  out  with  scientific  deliberation  and 
care.  He  could  not  agree  with  Mr.  Whitehead's  practice  of  not  ligaturing  the 
lingual  arteries. 

Mr.  Baewell  looked  upon  the  scissors  as  a  form  of  ecraseur.  It  was  very 
difficult  to  get  at  the  whole  of  the  diseased  tissues  when  they  were  situated  far 
back.  He  then  described  the  operation  which  he  had  devised,  and  which 
allowed  of  the  removal  of  the  tongue  as  far  back  as  the  base  of  the  epiglottis. 
The  wound  is  made  just  above  the  hyoid  bone,  and  through  this  opening  the 
wire  used  in  cutting  is  introduced. — Lancet,  Jan.  31,  1885. 

Malignant  Stricture,  of  the  Oesophagus. 
At  a  recent  meeting  of  the  Royal  Medical  and  Chirurgical  Society  Mr. 
Charters  J.  Symonds  read  an  account  of  a  case  of  malignant  stricture  of  the 
oesophagus  to  illustrate  the  use  of  a  new  form  of  permanent  oesophageal  catheter. 
The  patient,  a  man  aged  forty,  who  was  exhibited  wearing  one  of  the  tubes, 
gave  a  history  of  seven  weeks'  dysphagia  before  coming  under  treatment  on  June 
23,  1884.  At  that  time  he  was  unable  to  swallow,  and  it  was  impossible  to  pass 
a  bougie.  He,  however,  on  the  day  of  admission  managed  to  swallow  some 
milk,  and  in  a  few  days  took  fluids  freely.  The  first  tube  was  passed  on  July 
15th.  This  was  the  usual  long  oesophageal  catheter,  and  projected  from  the 
mouth.  It  proved  a  source  of  great  irritation,  and  had  to  be  removed  in  thirty- 
six  hours.  The  long  tube  induced  much  laryngeal  irritation,  and  by  plugging 
the  stricture  prevented  the  descent  of  the  saliva,  and  gave  rise  to  constant  expec- 
toration. The  tube  brought  before  the  society  by  Mr.  Symonds  was  designed  to 
remove  these  inconveniences  while  retaining  the  advantages  of  the  method  of 
treating  oesophageal  stricture  by  permanently  wearing  a  tube.  The  gum-elastic 
tube  is  about  six  inches  long  ;  one  end  expands  into  a  funnel  having  an  outside 
diameter  of  one-half  to  three-quarters  of  an  inch  ;  the  other  has  the  same  con- 
struction as  an  ordinary  catheter.  The  tube  is  passed  through  the  stricture,  the 
funnel  resting  on  its  upper  face,  thus  preventing  the  further  descent  of  the  tube. 
For  removing  it  a  piece  of  strong  silk  is  attached,  carried  out  of  the  mouth, 
looped  over,  and  fastened  behind  the  ear.  The  patient  had  worn  the  catheter 
since  July  15th.  It  has  been  changed  at  various  intervals — at  first  of  a  week, 
and  later  on  of  a  fortnight  and  three  weeks.  Xo  difficulty  was  experienced  in 
removing  the  tube,  nor  did  the  patient  suffer  any  inconvenience  from  its  presence. 
The  man  can  swallow  fluids  freely,  and  has  gained  in  weight.  The  advantages 
claimed  for  this  form  of  tube  are  that,  while  maintaining  a  passage  into  the 
stomach,  it  does  not  interfere  with  deglutition,  produces  no  irritation,  is  not 
unsightly,  and,  moreover,  retains  to  the  patient  the  pleasures  of  taste.  The  man 
is  able  to  move  about  with  comfort,  and,  except  for  the  silk  passing  out  of  his 
mouth,  is  not  aware  of  the  presence  of  the  tube.  It  was  suggested  that  if  the 
cases  of  this  disease  were  taken  earlier  a  large  tube  might  be  employed,  and  the 
patients  kept  in  comparative  comfort,  while  at  the  same  time  the  number  of  cases 
necessitating  gastrostomy  would  be  greatly  diminished.  It  was  the  desire  to 
avoid  this  operation,  often  so  unsatisfactory,  that  led  to  the  construction  of  the 
tube. —  Lancet,  Jan.  31,  1885. 

Penetrating  Wound  of  the  Posterior  Wall  of  the  Stomach — Suture  and 

Recovery. 

G.  Tiling,  in  the  St.  Peter sburger  Med.  Wochenschr.,  ~No.  44,  1884,  reports 
a  case  of  penetrating  wound  of  the  posterior  wall  of  the  stomach,  with  the  follow- 
ing history :  — 


1885.] 


Surgery. 


579 


Man,  aged  19,  received,  while  at  supper,  a  direct  thrust  of  a  knife,  producing 
a  diagonal  wound  four-fifths  of  an  inch  long,  an  inch  to  the  left  side  of  the  linea 
alba,  and  nearly  three  inches  above  the  umbilicus.  From  the  wound  a  portion  of 
the  omentum  protruded.  While  suturing  the  wound,  one  hour  after  the  injury, 
the  patient  vomited  great  quantities  of  chyme  of  a  reddish  color,  and  finally 
about  a  pint  of  pure  blood,  which  later  on  happened  again.  Laparotomy  was 
then  performed,  an  incision  about  six  inches  in  length  having  been  made  along 
the  linea  alba.  A  great  quantity  of  blood  escaped  from  the  abdominal  cavity, 
but  no  chyme  was  mingled  with  it.  No  wound  was  discoverable  on  the  anterior 
wall  of  the  stomach,  but  after  a  long  search  a  diagonal  wound  was  discovered  in 
the  left  gastro-colic  ligament,  through  which  the  finger  could  be  introduced  into 
the  omental  bursa.  On  feeling  the  posterior  smooth  wall  of  the  stomach  a  slight 
inequality  was  discovered ;  further  investigation  showed  this  to  be  a  wound 
through  which  the  mucous  membrane  of  the  stomach  protruded.  The  wound 
was  two  inches  above  the  greater  curvature  of  the  stomach. 

The  mucous  membrane  was  replaced  and  the  muscular  walls  united  by  three 
silk  sutures,  and  the  peritoneum  closed  by  four  of  Lembert's  sutures.  Owing  to 
the  collapse  of  the  patient  thorough  cleaning  of  the  abdominal  cavity  was  im- 
possible, since  the  abdominal  wound  was  closed  as  soon  as  possible.  The  patient 
received  for  the  first  five  days  milk  by  the  mouth.  There  was  no  fever,  and 
recovery  took  place  without  interruption. 

In  addition  to  the  interest  attached  to  the  case,  and  to  the  results  attending  the 
operation,  it  is  still  further  worthy  of  note,  because  confirming,  with  all  the  exact- 
ness of  direct  experiment,  the  opinion  now  commonly  held,  that  when  the  stom- 
ach is  full,  its  greater  curvature  turns  forward.  It  also  is  proven  that  the  posterior 
wall  of  the  stomach  may  be  injured  and  the  anterior  remain  intact.  The  favor- 
able termination  of  the  case  is  to  be  explained  by  the  fact  that  the  contents  of  the 
stomach  escaped  by  the  mouth,  and  did  not  enter  the  peritoneal  cavity  through 
the  wound. — Centralbl.  fur  Chirurgie,  Jan.  17,  1885. 

Incised  Wound  of  the  Anterior  Wall  of  the  Stomach. 

Dr.  Facilides-Reichexbach,  in  the  Deutsche  Med.  Wochenschr.  of  Dec. 
18,  1884,  reports  an  interesting  case  of  incised  wounds  of  the  stomach,  which 
terminated  favorably  notwithstanding  its  serious  nature. 

A  girl  7  years  old,  while  carrying  a  wine-flask,  fell,  and  the  flask  breaking 
and  a  fragment  perforating  the  epigastrium,  penetrated  the  anterior  wall  of  the 
stomach.  She  was  carried  into  a  neighboring  house,  where  a  midwife,  who  was 
accidentally  present,  removed  her  clothing  and  applied  carbolated  compresses  to 
the  wound.  Dr.  Reichenbach  was  then  called  to  the  case,  and  he  found  a  wound 
close  to  the  edge  of  the  ribs  a  little  to  the  left  of  the  mesial  line,  circular  in  out- 
line, and  about  2^  inches  in  diameter,  through  which  a  dark  red  tumor  protruded. 

The  child  was  then  anaesthetized  (by  chloroform)  and  the  projecting  tumor 
examined,  together  with  the  wound  through  which  it  escaped.  The  wound  on 
more  careful  examination  proved  to  be  about  2^-  inches  long,  and  the  projecting 
tumor  was  found  to  be  a  portion  of  the  stomach,  which,  slipping  through  the 
edges  of  the  wound,  was  firmly  held.  The  stomach  not  only  protruded,  but  was 
itself  wounded,  an  incision  the  same  length  as  the  external  wound  being  present, 
through  which  chyme  had  escaped.  The  stomach  was  then  drawn  slightly  for- 
ward, so  that  the  edges  of  the  wound  on  its  wall  could  be  more  easily  sutured, 
and  violent  vomiting  at  once  ensued.  This  lasted  for  some  time,  and  during  its 
continuance  the  edges  of  the  wounds  were  kept  in  apposition  so  that  none  of  the 
contents  of  the  stomach  escaped  through  it.  As  soon  as  vomiting  ceased,  five 
catgut  sutures  were  introduced  after  the  manner  of  intestinal  suture. 


580 


Progress  of  the  Medical  Sciences. 


[April 


The  protruding  parts  were  then  carefully  cleansed,  and  during  this  procedure 
the  peritoneum  was  also  discovered  to  be  included  in  the  abdominal  wound. 
At  this  time  the  child  began  vomiting  chyle  tinged  with  blood,  the  ejecta  having 
been  previously  pure  chyle  only.  No  assistant  being  at  hand,  Reichenbach  did 
not  attempt  to  close  the  peritoneal  wound,  but  completed  the  operation  by  sutures 
of  the  abdominal  wound,  six  silk  stitches  being  introduced  ;  external  dressing  of 
iodoform,  gauze,  and  salicylic  wadding  was  applied,  and  opium  internally  ad- 
ministered;  absolute  diet.  The  next  day  there  was  considerable  abdominal 
swelling,  especially  in  the  region  of  the  stomach  ;  vomiting  still  continued.  No 
pain  or  fever,  but  considerable  thirst.  The  vomiting  continued  one  day,  and  was 
followed  by  diarrhoea,  which  was  succeeded  shortly  by  constipation.  Milk  was 
first  given  on  the  fourth  day.  The  external  wound  healed  by  first  intention 
except  at  the  lower  angle,  where  it  healed  by  granulation.  The  stitches  were 
removed  in  six  days. 

In  three  weeks  the  child  was  able  to  leave  her  bed ;  her  appetite  was  good, 
and  she  is  now  entirely  well. 

Excision  of  the  Ccecum  for  Epithelioma ;  Death  on  the  thirteenth  day. 
Dr.  Walter  Whitehead,  in  the  British  Medical  Journal  of  January  24, 
1885,  reports  a  case  of  excision  of  the  caecum  for  epithelioma.    The  operation  is 
believed  to  be  the  first  performed  for  the  excision  of  the  caecum,  and  as  such  is 
worthy  of  record. 

The  clinical  features  of  the  case  undoubtedly  pointed  to  a  tumor  of  the  colon 
in  the  vicinity  of  the  csecum  ;  and  most  probably  a  rapidly  growing  epithelial  new 
formation.  The  tumor  being  movable,  it  appeared  reasonable  and  justifiable  to 
attempt  the  excision  of  the  whole  disease.  It  was  decided  beforehand  to  make 
the  incision  along  the  outer  border  of  the  rectus  muscle  in  preference  to  that  for 
lumbar  colotomy,  as  it  was  believed  that  it  would  allow  greater  facilities  for  deal- 
ing with  any  enlarged  mesenteric  glands  which  might  be  present,  and  be  better 
adapted  than  a  median  incision  for  the  establishment  of  an  artificial  anus.  The 
prudence  of  this  decision  was  confirmed  during  the  operation,  and  in  the  subse- 
quent progress  of  the  case. 

Operation. — Chloroform  was  administered.  The  surface  of  the  abdomen  was 
thoroughly  cleansed  and  dried ;  a  large  mackintosh,  with  an  aperture  five  by 
eight  inches  cut  out  of  the  centre,  and  the  under- surface  of  the  circumference  of 
the  aperture  made  adhesive  with  plaster,  was  fixed  to  the  skin,  so  that  the  open- 
ing corresponded  to  parts  that  would  be  involved  in  the  operation.  The  abdomen 
was  opened  in  the  ordinary  manner,  in  the  situation  previously  decided  upon, 
and  the  tumor  exposed.  Tt  was  examined,  and  found  to  be  situated  in  the  ascend- 
ing colon,  rather  than  in  the  caecum,  although  practically  involved  in  the  latter. 
It  was  deemed  advisable  to  detach  the  tumor  above  the  valve.  A  double  cat- 
gut ligature  was  first  passed  through  the  mesentery,  and  round  the  upper  part 
of  the  ascending  colon,  well  above  the  tumor.  The  ligatures  were  firmly  tied, 
and  the  bowel  divided  between  them.  The  cut  surfaces  of  the  bowel  were  freely 
washed  with  carbolic  lotion,  until  they  were  free  from  any  trace  of  feces.  A 
second  double  ligature  was  then  passed  round  the  ileum  in  the  same  manner,  and 
the  gut  divided  with  similar  precautions.  A  small  aperture  was  then  made 
in  the  upper  layer  of  the  mesentery,  through  which  the  fingers  were  passed,  and 
the  two  layers  of  the  mesentery  separated.  The  superior  layer  was  cautiously 
divided  close  to  the  bowel  by  the  use  of  scissors.  An  indurated  mesenteric  gland, 
of  the  size  of  a  split  walnut,  was  then  discovered  some  distance  from  the  growth, 
whilst  others  somewhat  smaller  were  found  inseparable  from  the  gut.    Up  to  this 


1885.] 


.Surgery. 


581 


stage  of  the  operation,  no  difficulties  whatever  had  been  met  with.  The  removal 
of  the  gland  being  deemed  essential  to  the  ultimate  success  of  the  operation,  a 
careful  dissection  was  commenced.  The  gland  had  almost  been  cleared  from  its 
surroundings,  when  a  sudden  gush  of  dark  blood  took  place,  the  origin  of  which 
it  was  impossible  to  determine  at  the  moment.  That  it  was  from  an  unusually 
large  vein  there  could  be  no  doubt,  and  for  a  time  the  vena  cava  was  suspected. 
Whilst  pressure  was  maintained  over  the  bleeding  aperture,  the  tissues  above  and 
below  were  separated,  and  finally  the  superior  mesenteric  vein  was  fully  exposed, 
and  found  distended  to  the  size  of  a  first  finger.  A  catgut  ligature  was  placed 
above  and  below  the  gland  round  the  vein,  and  the  intermediate  part  of  the  vein 
and  the  gland  removed  together.  The  other  layer  of  the  mesentery  was  then  cut 
across  without  any  bleeding,  and  the  mass  removed.  The  abdominal  cavity  was 
cleared 'of  all  the  blood,  which  had  amounted  to  very  little  throughout  the  opera- 
tion, notwithstanding  the  accident  to  the  vein.  The  ligature  was  then  removed 
from  the  small  bowel,  and  the  gut  stitched  to  the  skin  at  the  lower  end  of  the 
incision,  and,  after  removing  the  other  ligature,  the  colon  was  secured  to  the  skin 
at  the  upper  portion  of  the  wound.  A  very  large  number  of  silver  sutures  were 
employed  for  this  purpose,  and  great  pains  were  taken  to  leave  no  opening  for 
the  penetration  of  fecal  matter  into  the  deeper  tissues.  The  remaining  portion  of 
the  wound  was  next  brought  together  by  strong  silver  wire  passed  through  skin, 
muscle,  and  peritoneum.    The  surface  was  dressed  with  iodoform. 

The  patient  recovered  quickly  from  the  effects  of  the  chloroform,  and  expressed 
himself  as  feeling  very  comfortable.  During  the  first  days  succeeding  the  opera- 
tion his  condition  was  good,  but  the  sixth  day  unfavorable  symptoms  were  mani- 
fest. These  persisted  and  gradually  became  more  serious,  and  at  the  end  of 
thirteen  days  the  patient  died. 

The  portion  of  intestine  removed  included  the  last  two  inches  of  the  ileum,  the 
caecum  with  the  vermiform  appendage,  and  the  greater  part  of  the  ascending  colon. 
Its  total  length  from  the  lower  part  of  the  caecum  to  the  cut  end  of  the  colon 
measured  fourteen  inches,  whilst  from  the  ileo-caecal  aperture  to  the  cut  end  of 
the  colon  it  measured  nine  and  a  half  inches.  About  two  inches  beyond  the 
junction  of  the  ileum  with  the  caecum,  an  appearance  of  intussusception  was  ob- 
served, and  in  this  region  an  enlarged  and  indurated  lymphatic  gland  was  firmly 
united  to  the  intestinal  wall.  Corresponding  in  position  to  this  attachment,  the 
internal  surface  of  the  bowel  presented  a  fairly  defined  circular  area,  about  three 
inches  in  circumference,  occupied  by  an  irregular  fungoid  and  ulcerated  mass, 
which  projected  into  the  lumen  of  the  gut.  This  involved  only  the  inner  part  of 
the  intestinal  wall ;  the  remaining  part,  as  well  as  the  rest  of  the  intestine,  pre- 
sented a  healthy-looking  unbroken  mucous  lining,  nor  was  there  any  other  evi- 
dence of  invasion  of  the  wall  with  new  growth  beyond  the  area  mentioned. 

Remarks. — In  reviewing  this  case,  there  are  several  points  of  interest  which 
appear  worthy  of  brief  comment. 

The  diagnosis  was  made  without  difficulty,  which  is  unusual  in  cases  of  malig- 
nant disease  originating  in  the  colon,  especially  when,  as  most  frequently  occurs, 
the  disease  attacks  the  descending  portion  of  the  bowel.  The  protracted  diar- 
rhoea, the  local  character  of  the  pain  in  the  right  lumbar  region,  the  rapid  growth 
of  the  tumor,  the  freedom  with  which  it  moved  and  always  returned  to  the  situa- 
tion of  the  caecum,  and  the  quick  emaciation  of  the  patient,  pointed  with  marked 
precision  to  the  locality  and  nature  of  the  growth. 

Confident  of  the  diagnosis,  the  steps  of  the  operation  could  be  deliberately  de- 
signed, a  rare  advantage  in  operations  involving  the  intestines.  The  first  point 
to  determine  was  the  most  suitable  situation  to  open  the  abdomen.  The  reasons 
which  influenced  the  choice  in  this  instance  may  with  equal  force,  it  would  appear, 


582 


Progress  of  the  Medical  Sciences. 


[April 


be  applied  to  all  eases  of  malignant  disease  connected  with  any  portion  of  the 
colon  not  extending  beyond  the  sigmoid  flexure. 

The  median  incision  affords  more  room  for  general  exploratory  purposes  than 
any  other,  but  it  is  ill  adapted  for  the  establishment  of  an  artificial  anus,  and 
necessitates  a  second  incision  in  the  loin  for  that  purpose.  The  lumbar  opening 
is,  undoubtedly,  the  one  best  adapted  for  an  artificial  anus ;  but,  unfortunately, 
it  gives  no  room  for  the  removal  of  infiltrated  mesenteric  glands,  should  they 
exist.  Mr.  Bryant's  preference  for  the  lumbar  incision,  and  the  assertion  that 
five  or  six  inches  of  the  gut  can,  with  ease,  be  reached  and  examined,  does  not 
affect  this  all-important  question  in  suspected  malignant  disease.  An  intermediate 
incision,  made  three  inches  from  the  linea  alba,  combines  the  double  advantage — 
not  so  completely  perhaps  as  could  be  desired,  but,  nevertheless,  sufficiently  to 
be  accepted  as  a  practical  compromise  between  the  two.  In  this  case,  at  least,  it 
confirmed  the  judgment  which  was  exercised. 

The  second  point  to  decide  was  whether  or  not,  after  removal  of  the  growth, 
it  was  desirable  to  unite  the  divided  ends  of  the  bowel  together.  The  desire  to 
attempt  the  latter  course  was  naturally  great ;  but,  the  main  object  being  kept 
strictly  in  view,  it  was  not  considered  warrantable  to  subject  the  patient  to  such 
additional  risk,  especially  in  an  operation  which  only  holds  a  tentative  position  in 
surgery.  Whilst  admitting  the  wonderful  success  that  has  attended  the  operation 
of  enterorrhaphy,  it  cannot  at  present  be  regarded  as  an  established  precedent  free 
from  objections  and  disadvantages.  The  danger  of  non-union,  and  the  contin- 
gency, possibly  remote,  of  future  stricture,  are  risks  which  do  not  admit  of 
being  lightly  passed  over.  Further,  by  bringing  the  two  ends  of  the  bowel  out- 
side, there  always  remained  the  opportunity,  should  it  ever  be  considered  desir- 
able, of  uniting  them  by  a  subsequent  operation.1 

There  is  no  object  in  subjecting  a  patient  to  an  operation  attended  with  the 
greatest  risk,  unless  it  be  accompanied  with  a  firm  determination  to  remove  the 
whole  of  the  disease,  if  it  be  practicable  and  within  the  range  of  surgical  art.  If 
the  object  be  simply  to  temporize  and  relieve  pressing  symptoms,  such  as  those 
resulting  from  obstruction,  colotomy  will  accomplish  all  that  is  desired,  and  with 
considerably  less  risk  to  life. 

It  is  evident  from  the  post-mortem  examination  that  the  man  died  from  peri- 
tonitis, and  that  the  peritonitis  was  of  traumatic  and  not  of  septic  origin,  as  the 
inflammatory  indications  were  less  intense  as  it  receded  from  the  incision.  Each 
detail  of  the  operation  was  practically  successful.  All  the  parts,  with  the  excep- 
tion of  the  skin,  had  completely  united,  and  there  had  been  no  leakage  of  feces 
into  the  abdominal  cavity. 

In  looking  for  satisfaction,  after  the  termination  of  the  case,  one  has  to  be  con- 
tent with  the  reflection  that  the  patient  did  not  die  from  the  immediate  effects  of 
the  operation,  and  to  be  consoled  with  the  knowledge  which  the  post-mortem 
examination  affords — namely,  that  the  whole  of  the  disease  had  been  removed, 
and  the  certainty  that  the  patient  must  very  soon  have  succumbed  to  a  painful 
death  had  no  attempt  been  made  to  cure  him. 

The  operation  was  conducted  upon  strict  antiseptic  principles,  and  the  ab- 
dominal cavity  remained  aseptic  to  the  end.  There  was  complete  union  of  the 
peritoneum,  and  between  the  muscular  Avails  of  the  abdomen.    There  had  been 


1  Sir  Spencer  Wells,  in  his  Inaugural  Address  on  the  Revival  of  Ovariotomy  (British 
Medical  Journal,  1884,  November  15th,  p.  950),  states  that,  in  a  recent  paper  by 
Reich  el,  121  cases  of  resection  of  intestine  have  been  collected,  the  conclusion  being 
that  the  two  ends  of  the  bowel  should  not  be  united  at  the  time  of  resection,  but  that 
an  artificial  anus  should  be  established. 


1885.] 


Surgery. 


583 


no  secondary  hemorrhage,  nor  had  there  been  any  violent  sickness.  The  tem- 
perature was  even  remarkable  for  its  uniformity  at  or  about  the  normal  range. 

Taking  all  the  facts  of  the  case  into  consideration,  it  is  reasonable  to  suppose 
that,  had  the  man  possessed  a  less  dilapidated  constitution,  and  been  more  tem- 
perate in  his  habits,  complete  recovery  might  fairly  have  been  anticipated. 

Urethral  Fistules  of  the  Penis  and  their  Treatment. 

Dr.  Robert,  in  the  Annates  des  Malad.  des  Organes  Genito-Urin.  (Feb. 
1885),  after  commenting  upon  cases  of  urethral  fistulas  of  the  penis  which  have 
come  under  his  notice,  remarks  as  follows  upon  their  nature  and  treatment. 
Narrowing  of  the  urethra  is  not  a  necessary  complication  of  urethral  fistulas 
resulting  from  strangulation  of  the  penis,  neither  is  it  the  most  frequent  cause  of 
failure  in  its  treatment. 

Intractability  of  patients,  extensive  loss  of  tissue,  disorganization  of  the  skin 
surrounding  the  fistula  are  a  far  more  serious  hindrance  to  operative  success. 
The  use  of  the  sound  is  always  attended  with  inconvenience,  and  repeated  cathe- 
terization, notwithstanding  the  difficulties  attending  it,  is  much  more  preferable. 

Extended  incision,  according  to  the  method  of  Ricord,  and  recently  recom- 
mended by  Clutton,  offers  first  real  advantages,  but  renders  the  operation  more 
serious,  and  does  not  always  prevent  the  passage  of  urine  through  the  anterior 
wound.  Vesical  puncture,  recommended  by  M.  Tillaux,  may  be  resorted  to  when 
catheterization  is  difficult. 

Intraperitoneal  Rupture  of  the  Bladder. 
At  a  recent  meeting  of  the  Berlin  Medical  Society,  Dr.  Sonnenbueg  ex- 
hibited a  preparation  showing  an  intraperitoneal  rupture  of  the  bladder.  The 
patient,  a  healthy  man,  fell  down  stairs  and  was  carried  senseless  to  bed.  On 
regaining  consciousness  he  complained  of  strangury,  and  was  unable  to  void  his 
urine.  On  introducing  the  catheter,  blood,  and  then  urine,  in  great  quantity, 
about  two  quarts,  escaped.  Herr  Sonnenburg  first  saw  the  patient  24  hours  after 
the  injury  ;  examination  showed  the  abdomen  to  be  painful  under  pressure,  and 
suggillation  was  visible  near  the  symphysis  pubis.  On  the  introduction  of  the  cathe- 
ter, clear  urine  passed,  and,  therefore,  rupture  of  the  bladder  was  not  diagnosticated. 
The  pulse  was  something  above  80,  and  the  general  symptoms  favorable.  How- 
ever, after  24  hours  great  change  was  evident.  The  pulse  was  140,  and  opera- 
tion was  decided  upon.  Incision  was  made  in  the  linea  alba.  Upon  opening 
the  peritoneum,  a  quantity  of  fluid  escaped  which  was  partly  composed  of  urine. 
The  intestine  was  inflamed  and  showed  the  existence  of  incipient  peritonitis.  On 
the  posterior  wall  of  the  bladder  was  a  rent  extending  from  the  summit  nearly  to 
the  neck.  The  condition  of  the  patient  was  such  that  the  use  of  chloroform  was 
contraindicated,  and  suture  of  the  bladder  was  impossible.  Cleansing  of  the 
abdominal  cavity  was  resorted  to,  and  the  attempt  made  to  perfect  the  operation 
by  drainage.  The  following  day  the  pulse  was  scarcely  perceptible  and  the  ex- 
tremities perfectly  cold.  Consciousness  was  perfect,  however,  and  the  patient 
was  comfortable.  Strangury  had  ceased  and  the  urine  escaped,  in  part  through 
the  abdominal  opening,  and  in  part  normally.  The  third  day  the  temperature 
was  normal  and  the  pulse  perceptible,  and  a  series  of  days  succeeded  in  which  the 
symptoms  were  favorable,  and  danger  of  peritonitis  was  no  longer  apprehended. 
On  the  fifth  or  sixth  day  symptoms  of  beginning  urinary  infiltration  manifested 
themselves,  and  therewith  beginning  sepsis,  from  which  the  patient  died  on  the 
eighth  day.  Autopsy  showed  that  peritonitis  no  longer  existed,  but  that  the  entire 
pelvis  was  infiltrated  with  urine. — Deutsche  Med.  Wochenschr.,  Feb.  5,  1885. 


584  Progress  of  the  Medical  Sciences. 


Litholapaxy  performed  on  a  Tabetic  Patient. 

At  a  recent  meeting  of  the  Berlin  Medical  Society  Dr.  Furstenheim  reported 
a  case  of  tabes  in  which  litholapaxy  was  successfully  performed.  The  patient 
was  a  man  58  years  old,  of  good  family  history.  Symptoms  of  tabes  first  mani- 
fested themselves  about  twelve  years  ago.  Along  with  other  symptoms  of  the 
disease,  difficulty  in  voiding  the  urine  was  noticeable,  and  eventually  urinating 
became  impossible,  and  the  catheter  was  habitually  employed.  Cystitis  also 
was  a  complication  of  the  disease,  and  this  gradually  became  worse  in  spite  of 
all  treatment,  Examination  finally  revealed  the  presence  of  a  stone  in  the 
bladder.  It  was  movable,  of  moderate  size,  and  not  hard.  Lithotrity  was  decided 
upon,  and  the  operation  was  performed  under  chloroform.  Much  difficulty  was 
experienced  in  grasping  and  crushing  the  stone,  and  the  operation  was  left 
unfinished.  Only  a  small  portion  of  the  stone  was  removed,  but  great  improve- 
ment in  the  urinary  symptoms  followed,  and  urine  passed  spontaneously  for 
several  days,  and  along  with  it  small  fragments  of  the  calculus.  Improvement 
was  only  temporary,  however,  and  blood  finally  appeared  in  the  urine.  A  new 
operation  was  decided  upon,  and  litholapaxy  was  selected  as  being  most  advis- 
able. The  patient  preferred  to  undergo  the  operation  without  chloroform  and 
endured  the  introduction  of  the  instrument  well,  but  efforts  to  grasp  the  stone  gave 
him  so  much  pain  that  he  at  last  asked  for  the  anaesthetic.  The  stone  was  now 
quickly  grasped  and  crushed,  and  the  bladder  washed  out.  The  instrument  was 
introduced  five  times  in  all.  Carbolized  water  was  finally  injected  until  it 
returned  free  from  debris.    No  blood  was  lost  during  the  operation. 

No  unfavorable  symptoms  were  manifested,  and  the  day  succeeding  the  opera- 
tion the  patient  was  free  from  pain  and  fever,  and  the  urine  flowed  spontaneously. 
Within  a  week,  however,  it  again  became  necessary  to  resort  to  the  catheter. 
The  fragments  of  the  stone  weighed  about  100  grains,  and  were  composed  princi- 
pally of  the  phosphates  and  carbonate  of  lime,  with  traces  of  ammonio-magnesian 
phosphate  and  uric  acid. — Deutsche  Med.  Wochenschr.,  Jan.  29,  1885. 

Simultaneous  Double  Distal  Ligature  of  the  Carotid  and  Subclavian  Arteries 
for  High  Innominate  Aneurism. 

At  a  meeting  of  the  Royal  Medical  and  Chirurgical  Society  Mr.  Richard 
Barwell  read  a  paper  on  Simultaneous  Double  Distal  Ligature  of  the  Carotid 
and  Subclavian  Arteries  for  high  Innominate  Aneurism.  The  patient,  a  female, 
aged  forty-eight,  was  admitted  into  the  Charing-Cross  Hospital  on  February  16, 
1884.  She  was  thin,  pale,  and  anaemic.  Her  health  had  been  uninterruptedly 
good  until  eighteen  months  ago,  when  she  had  a  fall,  without  immediate  ill 
effects.  A  year  ago  she  noticed  a  sense  of  throbbing  at  the  upper  part  of  the 
right  side  of  the  chest,  and  very  soon  afterwards  neurotic  pains  and  loss  of  power 
in  the  right  arm.  On  admission  the  right  half  of  the  sternum,  the  two  upper 
costal  cartilages,  with  their  interspaces,  were  protruding  and  pulsatile.  In  the 
outer  half  of  the  episternal  notch,  and  behind  the  inner  head  of  the  right  sterno- 
mastoid  muscle,  was  a  pulsatile  tumor,  which  involved  the  carotid  artery.  The 
voice  was  very  low  and  toneless.  Very  little  air  entered  the  lungs.  The  apex 
beat  of  the  heart  was  not  displaced.  The  right  radial  pulse  was  very  small,  and 
ceased  altogether  four  days  after  admission,  when  no  pulse  could  be  felt  through- 
out the  arm  nor  at  the  third  part  of  the  subclavian  artery.  During  the  next 
twelve  days  the  patient  became  more  feeble,  less  air  entered  the  chest,  and  the 
line  of  dulness  rose  higher. 

On  February  28th  Mr.  Barwell  tied  the  carotid,  and  as  the  immediate  effect 
of  ligaturing  this  vessel  was  an  increased  pulsation  of  the  sac,  he  tied  the  third 


1885.] 


Surgery. 


585 


part  of  the  subclavian  also,  lest  the  obstruction  should  yield  and  the  aneurism 
again  increase  outward.  The  patient,  though  weak  and  disturbed  by  some  intes- 
tinal troubles,  went  on  well  until  March  28th,  when  recurrence  of  pulsation  in 
the  cervical  part  of  the  tumor  took  place  ;  this  continued  for  seventeen  days, 
when  it  diminished  and  soon  ceased  altogether,  and  definite  consolidation  fol- 
lowed. On  May  6th  she  left  the  hospital.  On  June  4th  she  showed  herself  at 
the  institution  ;  there  was  no  enlargement  at  the  upper  part  of  the  chest  nor  any 
tumor  to  be  felt  in  the  neck.  Over  the  site  of  the  late  aneurism  the  percussion 
note  was  clear,  and  the  respiratory  murmur  was  distinct.  No  pulse  could  be  felt 
in  any  branch  of  the  right  carotid  and  subclavian  arteries. 

Mr.  Barwell  believed  the  symptoms  clearly  indicated  a  high  innominate  aneu- 
rism involving  both  the  artery  and  its  bifurcation,  because  pain  in  the  right  arm 
was  a  very  early  symptom.  It  was  probable  that  the  disease  first  began  in  the 
subclavian  branch,  and  that  the  subsequent  affection  of  the  inner  side  of  the 
innominate  compressed  the  subclavian  and  that  portion  of  the  sac  arising  from 
the  subclavian  artery.  Anatomical  reasons  were  given  for  this  view,  and  atten- 
tion was  directed  to  the  absence  of  tumor  at  the  clavicular  part  of  the  sterno- 
mastoid  muscle.  In  his  remarks  the  author  dwelt  upon  the  spontaneous  cessation 
of  the  pulse  in  the  right  arm,  and  stated  the  means  he  had  taken  to  ascertain 
whether  cerebral  injury  would  follow  ligature  of  the  carotid  artery  in  this  case. 
No  cerebral  symptoms  were  caused  by  the  deligation,  although  probably  no 
blood  found  its  way  directly  to  the  right  side  of  the  brain.  He  also  drew  atten- 
tion to  the  return  of  the  lungs  to  the  normal  state.  Questions  were  propounded 
as  to  the  mode  in  which  soft  clots  in  aneurismal  sacs  were  disposed  of  when 
recurrence  of  pulsation  occurs. 

This  case  was  the  sixth  instance  of  double  distal  deligation  that  Mr.  Barwell 
had  brought  before  the  Society.  Of  these  five  had  been  successful,  the  one  nar- 
rated to  the  date  of  last  seeing  the  patient  (August,  1884)  perfectly  so.  He  said 
Mr.  Mitchell  Banks  had  brought  from  Liverpool  a  specimen  of  ligature  of  the 
innominate  artery. 

The  President  inquired  as  to  the  causation  of  the  aphonia.  He  said  the  loud 
ringing  brassy  cough  which  so  frequently  accompanied  aneurism  of  the  aorta  was 
almost  sufficient  for  the  diagnosis  of  the  disease. 

Mr.  Mitchell  Banks  had  performed  the  operation  of  simultaneous  double  dis- 
tal ligature  on  a  soldier  for  innominate  aneurism  rising  high  in  the  neck.  He  liga- 
tured both  the  carotid  and  subclavian  vessels  with  kangaroo  tendon  ligatures. 
The  patient  did  well  till  the  thirteenth  day,  when  there  appeared  a  fulness  and 
swelling,  which  steadily  increased,  and  were  found  to  be  due  to  extensive  effusion 
of  blood.  Death  followed  in  about  a  month,  and  then  it  was  found  that  the 
aneurism  had  been  nearly  occluded  by  laminated  clot.  The  subclavian  artery  at 
the  point  of  ligature  was  completely  destroyed,  and  this  explained  the  concealed 
hemorrhage.  The  question  must  still  be  considered  open  as  to  what  was  the 
best  material  for  ligaturing  the  great  vessels.  Kangaroo  tendon,  which  was  first 
used  by  Girdlestone,  seems  to  be  absorbed  too  readily ;  he  had  not  yet  used  liga- 
tures made  from  the  aorta  of  the  ox.  Nearly  all  the  cases  of  ligature  of  the  large 
arteries  about  the  region  in  question  died  from  secondary  hemorrhage,  and  a 
most  serious  question  was  the  material  to  be  used  as  a  ligature. 

Mr.  Timothy  Holmes  said  that  he  had  been,  and  still  remains,  at  issue  with 
Mr.  Barwell  as  to  the  best  method  of  treatment.  He  believed  that  the  best 
method  was  not  simultaneous  ligature  of  the  carotid  and  subclavian  arteries,  but 
ligature  of  the  carotid  artery  alone,  and,  if  necessary,  subsequent  ligature  of  the 
subclavian  artery.  The  most  successful  case  on  record  was  the  old  one  of  Evans, 
performed  in  1828,  in  which  the  patient  lived  for  nearly  forty  years  after  the 


.586 


Progress  of  the  Medical  Sciences.  [April 


ligature  of  the  carotid  artery,  and  then  died  from  some  unknown  cause.  This 
case  was  strikingly  like  that  described  by  Mr.  Barwell.  Occasionally  a  similar 
result  followed  ligature  of  the  left  carotid  for  aneurism  lower  down  ;  in  one  such 
case  of  aneurism  of  the  transverse  part  of  the  arch  of  the  aorta  in  a  young  woman 
an  excellent  result  followed.  The  first  case  reported  in  Mr.  Beaney's  pamphlet 
had  undergone  very  definite  improvement  after  the  application  of  the  ligature  to 
the  carotid  artery,  and  the  reason  for  the  subsequent  ligature  of  the  subclavian 
artery  in  this  case  was  not  evident.  The  lives  of  these  patients  were  precarious, 
and  it  was  important  to  recognize  that  ligature  of  the  subclavian  added  greatly 
to  the  risk  of  a  fatal  result.  Where  the  stress  of  the  aneurism  fell  chiefly  on  the 
subclavian  part  of  the  sac,  it  might  be  proper  to  deligate  that  vessel  first,  but  as 
a  rule  ligature  of  the  carotid  artery  produced  more  effect,  for  it  gave  off  no  such 
considerable  branches  as  does  the  subclavian  in  the  first  two  parts  of  the  course. 
Ligature  of  the  carotid  artery  completely  arrested  the  current  of  blood.  He 
considered  the  ox-aorta  ligature  a  very  much  better  ligature  than  catgut  prepared 
in  anyway;  the  kangaroo  tendon  also  formed  an  admirable  ligature,  and  the 
failures  with  it  were  probably  owing  to  not  pulling  the  ligatures  sufficiently  tight. 

Mr.  Howard  Marsh  congratulated  Mr.  Barwell  on  the  success  of  his  remark- 
able group  of  cases.  He  thought  the  discussion  of  the  treatment  of  aortic  and  of 
innominate  aneurisms  ought  to  be  kept  apart.  In  Mr.  Barwell' s  present  case  it 
should  be  borne  in  mind  that  the  pulsation  of  the  subclavian  artery  had  ceased 
before  the  ligature  was  applied  to  that  vessel.  He  considered  that  closure  of 
the  carotid  and  subclavian  arteries  at  the  same  time  was  really  not  often  effected  ; 
in  another  alleged  case,  for  instance,  the  carotid  was  all  but  occluded  at  the  time 
of  the  operation.  It  should  be  remembered  that  rapid  dilatation  of  the  arch  of 
the  aorta  followed  ligature  of  the  subclavian  artery.  He  agreed  with  most  of 
Mr.  Holmes's  remarks  on  the  value  of  ligature  of  the  carotid  alone.  In  one  case 
Mr.  Barwell  had  ligatured  the  carotid  so  loosely  that  the  lumen  of  the  vessel  was 
still  patent,  and  the  first  and  second  parts  of  the  subclavian  were  still  open. 
Reference  was  made  to  one  of  Mr.,  Heath's  cases  in  which  the  aneurism  affected 
the  ascending  part  of  the  arch  of  the  aorta,  and  which  was  greatly  benefited  by 
distal  ligature  of  the  carotid  artery.  He  considered  that  the  way  in  which  these 
operations  take  effect  in  different  cases  was  not  sufficiently  recognized.  With 
regard  to  the  kangaroo  ligature,  he  had  reason  to  be  satisfied  with  it  on  the 
whole,  though  in  the  hands  of  Mr.  Willett  and  of  himself  the  ligature  had  broken 
on  more  than  one  occasion.  In  the  sixty-sixth  volume  of  the  Royal  Medical  and 
Chirurgical  Transactions  an  account  of  a  case  operated  on  by  him  is  recorded 

Mr.  Spencer  Watson  had  used  kangaroo  tendon  and  ox-aorta  ligatures,  and 
did  not  think  it  necessary  to  cut  through  the  inner  and  middle  coats  of  the  artery, 
but  merely  to  bring  the  sides  into  apposition. 

Mr.  Barwell,  in  reply,  reviewed  the  cases  which  Mr.  Banks  and  Mr.  Heath 
had  recorded.  The  weakly  state  of  the  patients  would  rather  make  one  perform 
the  double  ligature  at  one  operation  than  expose  the  patient  to  the  risks  of  a 
second  operation  later  on.  Were  it  not  for  the  danger  of  the  operation,  he 
would  rather  ligature  the  first  part  of  the  artery,  in  order  to  cut  off  as  much 
blood  as  possible  from  the  aneurism. — Lancet,  Jan.  31,  18  85. 

The  Removal  of  the  Marrow  of  Long  Bones  and  the  Application  of  Corrosive 
Sublimate  Solution  and  Lodoform,  as  a  Treatment  of  Osteomyelitis. 
Dr.  Chas.  B.  Keetley,  in  an  interesting  article  on  this  subject,  gives  the 
results  of  his  experience  with  the  operation.    In  three  cases  cited,  the  removal  of 
the  marrow  of  the  bones  had  no  bad  effect — either  in  reducing  their  vitality  or 


1885.] 


Ophthalmology  and  Otology. 


587 


in  preventing  union.  In  two  cases  of  fracture,  one  of  which  occurred  during 
operation,  owing  to  the  presence  of  numerous  cloacae  in  the  bone,  sinuses  were 
also  present,  and  the  fracture  was  therefore  compound.  The  solution  of  corrosive 
sublimate  was  used  in  the  proportion  of  1  to  960.  The  iodoform  was  used  in  the 
form  of  the  concentrated  ethereal  solution.  The  shaft  of  the  bone  was  in  each 
case  thoroughly  disinfected  with  both  the  iodoform  and  mercury  solutions.  In 
addition  to  his  own  cases,  Dr.  Keetley  cites  those  of  Bleekwenn,  Stoll,  and  Pe- 
trowski,  all  of  whom  have  used  the  same  procedure  with  like  good  results.  Stoll 
and  Petrowski,  moreover,  have  filled  the  cavities  of  the  bones  operated  upon  with 
iodoform,  with  uniformly  favorable  results.  Petrowski  recommends  the  treat- 
ment in  gunshot  wounds  as  a  prophylactic  against  osteomyelitis,  so  frequent  and 
fatal  when  long  bones  are  hit.  Dr.  Keetley  considers  it  now  demonstrated  that 
the  medullary  cavity  of  a  long  bone  can  be  opened,  scraped  out,  drained,  and 
treated  locally  by  powerful  germicide  drugs,  and  that  the  operation  is  followed 
by  little  or  no  pain  or  constitutional  reaction  or  danger  to  the  life  of  the  bone — 
but,  on  the  contrary,  by  good  results. 

In  conclusion,  the  following  practical  observations  are  made  : — 

1.  In  the  face  of  Shede's  operation,  as  to  the  dangers  of  using  iodoform  too 
freely,  and  on  the  occasional  existence  of  idiosyncrasy  with  regard  to  that  drug, 
the  writer  would  hesitate  to  imitate  surgeons  who  fill  the  medullary  cavity  with 
it.    Moreover,  personal  experience  shows  it  is  superfluous  to  do  so. 

2.  If  the  shaft  of  a  long  bone  cannot  be  thoroughly  scraped  out  through  a  late- 
ral hole,  the  bone  may  be  completely  divided,  and  yet  a  speedy  and  thorough 
union  reckoned  on.  The  experiments  of  Maas  on  animals  proved  how  unneces- 
sary is  the  preservation  of  the  medulla  in  order  to  secure  union  of  fractures.  The 
writer's  personal  experience  shows  that  the  same  law  applies  to  the  human  sub- 
ject.— Annals  of  Surgery,  Jan.  1885. 


OPHTHALMOLOGY  AND  OTOLOGY. 

Ocular  Affections  in  Locomotor  Ataxia. 

M.  Galezowski,  in  La  Recueil  (V  Ophthalmologic  (May,  June,  and  July, 
1884),  gives  a  clear  and  methodical  r6sum&  of  the  various  ocular  disturbances 
which  are  met  in  locomotor  ataxia. 

These  affections  may  be  manifested  upon  the  optic  nerve,  upon  the  motor  mus- 
cles, or  upon  the  trifacial. 

The  alterations  of  the  optic  nerve  are  especially  interesting  from  the  time  of 
their  first  appearance,  inasmuch  as  they  are  easily  confounded  with  the  changes 
due  to  toxic  emblyopia. 

In  locomotor  ataxia  visual  acuteness  is  nearly  always  unequal  in  the  two  eyes. 
Patients  may  be  unable  longer  to  see  green  and  red.  On  the  other  hand,  read- 
ing at  short  distance  is  possible  for  a  long  time,  while  acuity  of  vision  for  dis- 
tant objects  is  much  diminished.  Finally,  as  has  been  shown  by  M.  Darier,  a 
much  stronger  electric  current  is  required  to  produce  manifestations  of  light  in 
the  beginning  of  ataxia  than  in  toxic  amblyopia. 

In  the  branches  of  the  fifth  pair  which  border  upon  the  eye,  anaesthesia,  and 
sometimes  hyperesthesia,  are  observed. 

The  spots  where  anaesthesia  is  present  rarely  are  acknowledged  by  the  patient, 
but  to  be  discovered  must  be  sought  for  with  care.    Sometimes  patients  com- 


588 


Progress  of  the  Medical  Sciences. 


[April 


plain  of  a  feeling  of  heaviness  in  the  peri-orbital  region  and  in  the  face,  can  no 
longer  feel  the  contraction  of  the  muscles  of  this  region,  and  frequently  use  the 
hand  to  assist  the  motion  of  the  part. 

Hyperesthesia  is  manifested  by  neuralgia,  or  by  lancinating  pains  similar  to 
those  experienced  in  the  lower  limbs.  Excavation  of  the  optic  papilla?,  -which 
resembles  the  changes  due  to  glaucoma,  accompanies  these  manifestations  of  pain. 

These  diverse  affections  have  hitherto  resisted  treatment,  but  Galezowski, 
agreeing  with  Fournier  as  to  the  commonly  syphilitic  origin  of  the  disease,  ad- 
vises at  the  beginning  of  the  attack  vigorous  anti-syphilitic  treatment.  He 
advises  hypodermic  injections  of  5  or  6  drops  of  a  solution  of  cyanide  of  mer- 
cury of  1^-  grs.  to  5  drachms  of  distilled  water.  At  a  more  advanced  period, 
when  the  organism  is  saturated  with  mercury,  he  employs  hypodermic  injections 
of  cyanide  of  gold  and  potassium,  which,  in  some  cases,  have  given  marked  suc- 
cess; but  in  others  they  have  totally  failed. — Gazette  MSdicale  de  Paris, 
December  27,  1884. 

Amaurosis  due  to  Anwsthesia  of  the  Optic  Nerve. 

M.  Dianoux,  in  the  Bulletin  de  la  Societi  Frangaise  d'  Ophthalmologic, 
makes  some  interesting  observations  upon  this  not  very  rare  variety  of  blind- 
ness, though  few  cases  have  hitherto  been  published.  The  symptoms  are  briefly 
these :  abrupt  beginning,  generally  during  sleep  or  subsequent  to  some  violent 
emotion,  and  ushered  in  by  a  feeling  of  weight  in  the  fronto-parietal  region. 
Blindness  is  at  first  absolute,  and  the  patient  cannot  distinguish  night  from  day. 
The  blindness  attacks  almost  indifferently  the  right  or  left  eye,  in  contrast  to 
what  takes  place  in  hysterical  amaurosis,  which  is  habitually  connected  with 
hemi-ansesthesia.  It  usually  is  mono-lateral,  but  may  affect  both  eyes.  Once 
developed,  it  lasts  indefinitely.  Examination  of  the  eye  gives  entirely  negative 
results,  and  the  ophthalmoscope  reveals  no  indications  of  disease.  Without  any 
treatment,  the  affection  may  have  three  different  conclusions :  it  may  either  be 
cured  spontaneously,  persist  a  long  time  without  change,  or  the  optic  nerve 
gradually  may  pass  into  a  condition  of  atrophy. 

Diagnosis  of  anaesthesia  of  the  optic  nerve  is  easy ;  the  absence  of  every  oph- 
thalmoscopic lesion  enables  all  affections  of  the  fundus  of  the  eye  to  be  excluded. 
Amblyopia  due  to  alcoholic  or  nicotine  poisoning  never  causes  such  extensive  per- 
version of  vision  without  sign  of  atrophy,  and  amauroses  of  cerebral  origin  are 
always  accompanied  by  hemiplegia  or  hemi-anaesthesia.  The  prognosis  of  this 
^variety  of  blindness  is  in  most  cases  favorable,  with  certain  reserve,  however,  as 
the  graver  changes  sometimes  occur.  Moreover,  treatment  is  important  as  a 
criterion,  since  in  favorable  cases  amelioration  is  almost  immediate. 

The  treatment  consists  in  the  use  of  cod-liver  oil,  iron,  and  quinine  in  appro- 
priate doses.  Uterine  disturbances  should  be  inquired  after,  and  carefully  treated. 
Locally  strong  injections  of  strychnia  should  be  used  ;  TJ5  grain  injected  into  the 
temple.  The  continued  galvanic  current  gives  the  best  results  of  all  electric  appli- 
cations, the  positive  electrode  being  placed  behind  the  mastoid  protuberance,  and 
the  negative  applied  to  the  closed  eyelids. — V  Abeille  Medicate,  Jan.  5,  1885. 

Hypodermic  Injection  of  Pilocarpin  in  A  ffections  of  the  Labyrinth. 
Prof.  Adam  Politzer,  at  a  late  meeting  of  the  Medical  Society  of  Vienna, 
recommended,  as  the  result  of  several  years'  experience,  the  subcutaneous  in- 
jection of  the  muriate  of  pilocarpin  in  the  treatment  of  deafness  due  to  disease 
of  the  labyrinth,  in  order  to  promote  the  absorption  of  the  exudation  which  may 
be  in  the  labyrinth  through  the  rapid  tissue  change  which  the  drug  produces. 


1885.] 


Ophthalmology  and  Otology. 


589 


Gradually  increasing  doses  of  2,  3,  4,  5,  6  drops  of  a  two  per  cent,  solution  were 
injected  daily  into  the  forearm.  Extreme  symptoms  of  salivation  and  perspiration, 
and  the  incipient  symptoms  of  severe  vomiting,  were  quickly  allayed  by  two 
drops  of  a  solution  of  atropise  sulph.  in  water  (gr.  ss  to  3iiss  water).  The  number 
of  injections  varied  from  six  to  forty. 

The  favorable  results  in  the  treatment  of  syphilis  of  the  labyrinth  have  already 
been  reported.  In  eleven  cases,  five  of  recent  origin  improved  and  six  received 
no  benefit.  In  one  case,  the  distance  at  which  loud  speech  could  be  heard  was  in- 
creased from  zero  to  sixteen  and  one-half  feet.  In  a  second  case,  in  which  loud 
speech  could  be  distinguished  only  at  a  distance  of  thirteen  inches,  the  hearing 
improved  until  whispering  could  be  distinguished  at  a  distance  of  nearly  twenty- 
three  feet. 

Prof.  Politzer  also  cites  a  case  in  which  non-syphilitic  disease  of  the  ear  was 
much  benefited  by  the  use  of  pilocarpin.  The  patient  was  deaf  in  the  left  ear 
for  two  years,  and  in  the  right  completely  deaf  for  nine  months  ;  after  seventeen 
injections  rapid  improvement  began,  and  at  the  end  of  the  third  week  the  hear- 
ing, with  the  exception  of  acoustic  hyperesthesia,  was  nearly  normal.  Unfavor- 
able results  obtain  in  the  use  of  pilocarpin  in  pan-otitis,  cotemporaneous  inflam- 
mation of  the  middle  and  internal  ear. 

Other  specialists  have  used  pilocarpin  on  the  recommendation  of  Prof.  Politzer. 
Prof.  Lucas,  of  Berlin,  in  thirty-five  cases  obtained  remarkable  results  in  five, 
slight  benefit  in  six,  and  in  twenty-four  no  improvement.  Profs.  Moos  and  Wolf, 
in  two  cases  of  middle  ear  disease  due  to  scarlatino-diphtheria,  in  which  there 
was  total  deafness,  observed  the  restoration  of  hearing  after  a  long  use  of  weak 
pilocarpin  injections. — Allgemeine  Wien.  Med.  Zeitung.,  Jan.  20,  1885. 

Exfoliation  of  the  Cochlea  without  Loss  of  Hearing. 
The  loss  of  the  cochlea,  according  to  the  ingenious  researches  of  Helmholtz,  is 
considered  to  be  equivalent  to  the  loss  of  hearing  power.  A  case,  however,  which 
Professor  Griiber  demonstrated  on  Dec.  12th,  at  the  meeting  of  the  Society  of 
Physicians  in  Vienna,  would  seem  to  go  far  towards  refuting  this  view.  The  case 
occurred  in  a  lad,  aged  fourteen,  who  had  been  ailing  for  four  years,  and  who  was 
admitted  into  Professor  Griiber' s  wards  last  November.  It  was  stated  that  the 
patient  suffered  from  an  old  otorrhoea  with  polypus  of  the  left  ear.  As  the  patient 
experienced  great  pain,  and  as  paralysis  of  the  left  facial  nerve  existed,  Pro- 
fessor Griiber  had  no  hesitation  in  entirely  removing  the  polypus,  and  in  doing  so 
came  upon  the  cochlea  in  a  state  of  necrosis.  Since  the  operation  the  patient  has 
felt  better,  his  pains  have  ceased,  and  the  paralysis  of  the  facial  nerve  has 
nearly  disappeared  ;  but,  strange  to  say,  the  lad's  affected  ear  has  regained 
the  power,  not  only  of  recognizing  sounds,  but  of  distinguishing  musical  notes. 
Only  two  similar  cases  seem  to  have  been  recorded.  One  was  observed  by 
Dr.  Cassols,  at  Glasgow,  the  other  by  Dr.  Christinneck,  in  the  clinic  of  Prof. 
Schwarze  at  Halle.  Prof.  Griiber  did  not  enlarge  on  the  features  of  this  interest- 
ing case  ;  but  it  certainly  affords  food  for  suggestive  thought  in  reference  to  treat- 
ment of  diseases  of  the  ear.  Heretofore,  the  labyrinth  was  considered  a  sort  of 
noli  me  tangere;  but  now  we  see  that  the  entire  cochlea  may  be  missing,  and  yet 
the  aural  powers  be  retained.  On  the  other  hand,  it  is  not  yet  quite  certain 
whether  in  the  above  case  paralysis  of  the  auditory  nerve  may  not  eventually 
occur. — Lancet,  Jan.  3,  1885. 

Treatment  of  Deaf -mutism  caused  by  Auricular  Compression. 
Dr.  Bo u che ron,  at  the  conclusion  of  a  valuable  paper  upon  deaf-mutism, 
caused  by  auricular  compression,  reaches  the  following  conclusions  relative  to  the 
treatment  of  the  affection  : 

JNTo.  CLXXVIII  April,  1885.  38 


590 


Progress  of  the  Medical  Sciences. 


[April 


The  compression  of  the  acoustic  nerves  has  its  origin  in  the  vacuum  existing 
in  the  tympanum,  caused  by  the  absorption  of  the  air  by  the  vessels  of  the  ear 
cavity.1 

The  vacuum  is  rapidly  reproduced  when  the  air  cannot  easily  be  renewed. 
The  first  indication  is  to  abolish  the  tympanic  vacuum  as  often  as  it  is  repro- 
duced. 

When  the  vacuum  in  the  cavity  persists  for  some  time  the  atmospheric  pres- 
sure depresses  the  tympanic  membrane,  drives  down  the  ossicles,  and  fixes  them 
in  a  vicious  position. 

This  gives  rise  to  inflammation  of  the  mucous  membrane,  causing  thickening 
and  the  production  of  new  connective  tissue.  The  newly-formed  elements  become 
organized  and  retract,  and  the  retraction  tends  still  further  to  immobilize  the 
stapes  and  other  ossicles  in  their  mal-position. 

Therefore,  this  position  may  persist  after  the  disappearance  of  the  tympanic 
vacuum,  and  the  effects  of  the  auricular  pressure  outlast  its  original  cause. 

The  second  indication  is  to  return,  by  means  of  pressure  without  the  tympanic 
membrane,  the  ossicles,  and  especially  the  stapes,  to  their  correct  position,  and  to 
mobilize  them  as  much  as  possible. 

The  affection  which  causes  most  frequently  a  vacuum  of  the  tympanic  cavity 
is  obstruction  of  the  Eustachian  tube,  by  an  auriculo-tubal  catarrh,  which  is 
either  accidental,  constitutional,  or  hereditary. 

The  third  indication  is  to  cure  such  catarrh  and  to  resort  to  proper  treatment 
when  it  is  of  constitutional  origin. 

The  fourth  indication  is  to  stimulate  the  labyrinthian  nerves,  anaesthetized  by 
compression. 

The  fifth  indication  is  to  educate  the  sense  of  hearing,  if  ability  to  distinguish 
speech  remain. 

The  sixth  indication  is  to  instruct  by  artificial  methods  if  hearing  is  partial, 
insufficient,  or  wanting. 

The  treatment  of  the  condition  above  described  varies.  The  first  and  second 
indications  are  fulfilled  by  insufflations  of  air  into  the  tympanum  by  catheteriza- 
tion. Young  children  should  be  anesthetized  preparatory  to  undergoing  this 
operation.  Dr.  Boucheron  employs  the  method  of  Saint  Germain,  which  requires 
but  five  or  six  inspirations  of  chloroform.  Its  results  are  uniformly  pleasant  and 
safe. 

Perforation  of  the  tympanic  membrane  and  section  of  the  muscles  of  the  mal- 
leus are  also  employed  when  required  by  the  preceding  indications. 

Politzer's  bag  is  employed  after  such  operation  when  the  ossicles  and  membrane 
have  resumed  their  proper  position,  in  order  to  maintain  the  correction.  Its  use 
is  also  advisable  in  new-born  children,  in  families  of  deaf-mutes,  when  naso-pha- 
ryngeal  catarrh  with  auricular  complications  is  to  be  feared. 

Naso-pharyngeal  catarrh  should  be  treated  by  astringents  or  by  general  medi- 
cation according  to  the  symptoms  and  the  diathesis  of  the  patient. 

When  the  Eustachian  tubes  are  open  and  the  nerves  compressed,  the  feeble 
continued  current  may  be  employed. 

Early  instruction  in  speech,  either  by  the  aid  of  hearing  when  the  voice  can  be 
perceived  or  by  artificial  methods,  when  the  sense  of  hearing  is  lost,  is  important. 
— Revue  Mens,  de  Laryngol.  d'Otol.  et  de  Rhino  I. ,  Feb.  1885. 


1  The  rapidity  with  which  air  introduced  beneath  the  skin  by  the  Irypodermic  syringe 
is  absorbed,  is  well  known,  and  the  absorption  of  the  air  in  the  tympanic  cavity  is 
accomplished  in  the  same  manner  by  the  same  physiological  laws. 


1885.] 


Midwifery  and  Gynaecology. 


591 


MIDWIFERY  AND  GYNAECOLOGY. 

Corrosive  Sublimate  in  Obstetrics. 

Two  cases  of  mortal  poisoning  by  uterine  injections  of  Yon  Swieten's  fluid 
are  actually  known  to  have  occurred.  They  are  reported  by  Drs.  Stadtfkldt 
and  Stenger.  They  are  perhaps  debatable,  but  should  lead  the  accoucheur  to 
use  corrosive  sublimate  only  with  certain  precautions,  and  with  a  knowledge  of 
the  reason  therefor.  This  reserve  made,  corrosive  sublimate  nevertheless  remains 
the  best  antiseptic  in  obstetrics.  The  statistics  furnished  by  the  different  mater- 
nities of  Paris,  and  particularly  by  those  in  the  service  of  Prof.  Tarnier,  where 
the  agent  has  been  employed  for  the  first  time,  are  sufficient  evidence  on  this 
point.  Hofmeier  reports  the  cases  above  referred  to  in  the  American  Journal  of 
Obstetrics  for  September,  1884.  The  first  case  was  that  of  a  primipara,  set.  25, 
who  had  been  long  in  labor,  and  showed  some  symptoms  of  fever  during  the 
delivery.  The  soft  parts  were  very  unyielding,  requiring  some  slight  incisions, 
and  the  patient  was  delivered  with  forceps.  There  being  some  atony,  hot  in- 
jections of  corrosive  sublimate,  1  :  1000,  were  given.  During  the  first  days  of 
the  puerperium  the  patient  presented  some  very  peculiar  symptoms :  general 
depression,  then  a  comatose  state,  together  with  a  certain  hyperesthesia  of  the 
whole  body,  subnormal  temperature,  and  offensive  diarrhoea.  About  the  fourth 
or  fifth  day  these  symptoms  abated.  The  patient  had  some  puerperal  abscesses, 
for  which  she  continued  under  treatment  for  some  time  at  her  house.  Albumen 
was  present  in  her  urine  a  considerable  time  from  the  first  day  on. 

The  second  case  was  that  of  an  eclampsic  primapara,  aet.  25  ;  the  eclampsia  on 
the  whole  ran  a  benign  course  ;  the  patient  was  delivered  by  the  forceps  without 
material  difficulty.  After  delivery  there  was  some  degree  of  uterine  atony,  for 
which  a  hot  irrigation  with  about  six  pints  of  a  1  :  1000  corrosive  sublimate  solution 
was  given.  The  hemorrhage  ceased,  and  the  patient  soon  recovered  conscious- 
ness. On  the  days  succeeding  delivery  there  appeared  great  hyperesthesia,  sub- 
normal temperature,  and  profuse  fetid  diarrhoea.  The  patient  became  somewhat 
somnolent,  and  death  ensued  on  the  fourth  day.  The  autopsy  again  showed  the 
most  extraordinary  alterations  in  the  intestinal  mucosa,  which  was  enormously 
swollen  and  partly  gangrenous  as  far  as  the  transition  into  the  ileum,  but  espe- 
cially so  in  the  rectum.  The  kidneys  showed  marked  deposits,  although  cal- 
careous deposits,  as  in  Stadtfeldt's  case,  could  not  be  found.  From  these  cases 
Hofmeier  concludes  that  the  condition  of  the  kidneys  has  much  to  do  with  the 
poisonous  effect  of  the  sublimate.  The  conclusions  seem  entirely  justifiable  when 
it  is  remembered  that  these  organs  play  a  very  important  part  in  the  excretion  of 
many  toxic  drugs.  For  example  :  opium  and  its  derivatives  are  contraindicated, 
or  should  be  administered  with  great  caution,  in  cases  of  nephritis.  In  1873 
Bouchard  published  two  cases  of  mercurial  poisoning  terminating  in  death  in  two 
patients  :  one  a  case  of  interstitial,  the  other  of  parenchymatous  nephritis.  Only 
small  doses  of  the  drug  were  taken.  It  therefore  seems  established  that  slight 
renal  disease  entails  great  caution  in  the  use  of  corrosive  sublimate,  and  that  in 
extended  degeneration  of  the  organs  its  use  is  altogether  contraindicated. — D  Union 
MMicale,  Jan.  6,  1885. 

A  Successf  ul  Case  of  Laparo-Elytrotomy. 
In  the  Annals  of  Surgery  for  Jan.  1885,  Dr.  Alex.  J.  C.  Skene  reports  a 
case  of  laparo-elytrotomy  which  is  the  ninth  on  record,  and  the  fourth  on  which 
Dr.  Skene  has  operated;  three  of  his  four  operations  having  been  successful. 
The  patient  was  twenty-one  years  of  age,  and  when  a  child  was  the  subject  of 


592 


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rickets.  She  was  a  patient  of  Dr.  L.  S.  Pilcher,  who,  upon  examination,  found 
the  antero-posterior  diameter  of  the  superior  strait  to  be  as  he  supposed  less 
than  two  inches. 

Dr.  Skene  having  been  called  in  consultation,  an  operation  was  decided  upon, 
and  laparo-elytrotomy  was  selected  as  being  preferable  to  craniotomy.  The 
usual  incision  was  made  in  the  left  groin,  in  which  the  internal  epigastric  artery 
was  divided,  but,  being  secured  by  a  Pean  forceps,  caused  no  further  trouble.  In 
incising  the  wall  of  the  vagina  a  minute  opening  was  made  into  the  bladder. 
There  was  some  difficulty  in  effecting  complete  dilatation  of  the  uterus,  but  this 
at  length  being  accomplished,  a  living  male  child,  fully  developed  and  weighing 
seven  pounds,  was  delivered  by  version  through  the  wound  in  the  groin.  The 
placenta  was  likewise  delivered. 

The  wound  in  the  groin  was  closed  by  carbolized  silver  sutures,  and  a  soft 
rubber  draining  tube  carried  from  the  inner  angle  of  the  incision  downward 
through  the  incision  and  out  of  the  vaginal  entrance.  No  attention  was  paid  to 
the  tear  in  the  bladder,  but  a  self-retaining  catheter  was  inserted  into  the  bladder. 
The  case  progressed  favorably  ;  the  temperature  rising  above  100°  F.  but  once 
(on  the  second  day)  on  account  of  imperfect  drainage.  On  the  fourth  day  there 
was  the  ordinary  mild  fever,  during  which  the  temperature  rose  to  100.25°  for  one 
day.  On  the  twenty-first  day  after  the  operation  the  catheter  was  removed,  and 
the  patient  allowed  to  sit  up.  Vesical  irritability  at  this  time  necessitated  mictu- 
rition every  two  hours.  In  two  weeks  the  urine  could  be  retained  about  three 
hours. 

Concerning  the  operation  Dr.  Skene  remarks,  that  before  beginning  it  sufficient 
dilatation  of  the  cervix  is  important ;  that  there  is  no  great  danger  from  hemor- 
rhage ;  and  that  in  the  four  cases  operated  on  by  him  it  has  not  been  necessary  to 
ligate  a  single  vessel ;  and  that  the  loss  of  blood  has  not  been  greater  than  that  in 
normal  labor.  He  further  observes  that  great  care  is  necessary  to  avoid  injuring 
the  bladder,  though  this  accident  when  it  occurs  is  trifling,  as  is  proven  in  this 
case  by  the  wounds  having  healed  without  the  introduction  of  sutures. 

Prophylaxis  of  Post-partum  Hemorrhage. 

Dr.  Glynn  Whittle,  after  discussing  the  treatment  of  post-partum  hemor- 
rhages, makes  the  following  suggestions  as  to  the  prophylaxis  of  this  so  serious 
accident  of  child-bed :  — 

In  these  cases  of  apprehended  hemorrhage,  while  it  is  important  to  follow  down 
the  uterus  with  the  hand,  we  should  nevertheless  be  in  no  hurry  to  get  the  pla- 
centa expelled,  but  wait  a  quarter  of  an  hour  or  twenty  minutes  to  give  the  uterus 
time  to  recover  from  the  strong  efforts  required  to  expel  the  child.  But  should 
flooding  commence,  it  will  of  course  be  necessary  to  remove  the  placenta.  Well- 
directed  and  careful  manipulation  of  the  uterus  from  the  moment  of  the  child's 
birth  contributes  much  to  the  prevention  of  hemorrhage,  and  is  a  precaution  of 
not  less  importance  than  the  administration  of  ergot  before  the  expulsion  of  the 
foetus. 

As  a  deficiency  in  the  coagulating  power  of  the  blood  is  a  predisposing  cause  of 
post-partum  hemorrhage,  astringent  medicines  should  be  administered  for  some 
time  previous  to  the  delivery  of  ansemic  women.  Gallic  acid  and  sulphate  of 
zinc  have  been  recommended  for  this  purpose,  but  J  believe  that  the  remedy  on 
which  most  reliance  may  be  placed  is  the  tincture  of  perchloride  of  iron. 

Notwithstanding  what  differences  of  opinion  in  matters  of  detail  may  exist,  the 
conclusions  of  writers  on  this  subject  agree  on  all  the  main  points,  which  may  be 
thus  summed  up:  — 


1885.] 


Midwifery  and  Gynaecology. 


593 


First.  That  post-partum  hemorrhage  has  certain  premonitory  symptoms,  and 
that  these  symptoms  are  to  be  found  in  the  characteristic  pains,  and  in  the  condi- 
tion of  the  circulation  and  the  blood. 

Secondly.  That  flooding  can  be  averted  by  appropriate  prophylactic  measures, 
the  preventive  treatment,  consisting  of  rupturing  the  membranes,  administering 
ergot  of  rye,  extracting  the  foetus  slowly,  and  following  down  the  uterus  with  the 
hand. — Liverpool  Medieo-Chirurgical  Journal,  Jan.  1885. 

Treatment  of  the  Umbilicus  in  the  New-born. 
Crede  and  Weber,  in  the  Archiv  fur  Gyncekologie,  Band  xxiii.  Heft  1, 
give  directions  for  the  management  of  the  umbilicus  in  the  new-born. 

1.  It  is  preferable  to  wait  four  or  five  minutes  before  applying  a  ligature  to  the 
cord.  If  the  ligature  is  .immediately  applied,  a  certain  quantity  of  blood  is 
diverted  from  the  child's  circulation. 

The  best  method  of  ligature  is  with  caoutchouc  (small  drainage-tubes),  first 
suggested  by  Budin.  Hitherto,  fillets  of  thread  were  employed  at  the  Leipsic 
clinic,  and  scarcely  a  week  passed  in  which  consecutive  hemorrhage  did  not  occur. 
Since  the  first  of  July,  1883,  caoutchouc  tubes  have  been  employed,  and  not  a 
single  case  of  hemorrhage  has  occurred.  A  single  turn  of  the  rubber  tube  gene- 
rally suffices  to  obviate  all  danger  of  hemorrhage,  and  two  turns  render  hemor- 
rhage absolutely  impossible. 

The  rubber  ligature  also  has  the  advantage  of  being  able  to  be  applied  very 
close  to  the  abdomen,  thus  diminishing  the  length  of  cord  to  be  eliminated. 

2.  A  little  wadding  held  in  place  by  the  umbilical  bandage  is  sufficient  dress- 
ing for  the  cord.  The  wadding  should  be  renewed  each  morning  after  the 
bath,  which  has  no  bad  effect  upon  the  rapid  shrivelling  of  the  cord.  Wadding 
as  a  dressing  for  the  cord  has  the  advantage  over  all  other  applications,  that  it 
filters  the  air,  and  thus  debars  the  entrance  of  putrefactive  germs,  and  should  be 
continued  till  cicatrization  is  complete.  Since  the  introduction  of  this  dressing 
at  Leipsic,  many  years  ago,  affections  of  the  cord  have  been  almost  unknown. 

A  Case  of  Hysterectomy. 
At  a  recent  meeting  of  the  Societe  de  Chirurgie  de  Paris,  M.  Terrier  reported 
an  operation  of  hysterectomy  which  he  lately  performed.  The  patient  for  twelve 
years  had  suffered  crises  of  pain,  comparable  with  those  of  child-birth,  occurring 
either  during  the  menstrual  period  or  the  interval  between  them.  The  tumor 
was  first  perceived  six  years  ago ;  grew  rapidly,  and  caused  severe  pain.  Re- 
duced by  suffering,  the  woman  twice  entered  the  HSpital  St.  Louis,  and  once 
a  church  hospital  with  the  intention  of  undergoing  an  operation,  which,  however, 
was  not  performed. 

When  M.  Terrier  first  saw  the  patient  her  condition  was  as  follows  :  The  belly 
very  voluminous,  being  about  forty-six  inches  in  circumference  at  the  level  of  the 
umbilicus,  asymmetrical,  filled  by  an  enormous  lobulated  tumor,  which  extended 
downward  as  far  as  the  utero-rectal  cul-de-sac.  The  uterus  had  ascended  behind 
the  pubes,  drawn  to  some  extent  upward  and  forward  by  the  tumor.  The  gene- 
ral condition  of  the  patient  was  good,  but  constipation  frequently  existed,  and  the 
urinary  function  was  somewhat  interfered  with,  being  at  times  natural  and  again 
difficult  and  irregular.  Exploratory  puncture  evacuated  about  eleven  pints  of  a 
reddish-black  color,  containing  the  elements  of  blood.  Diagnosis  was  made  of 
fibro-cystic  tumor  of  the  uterus. 

Operation  was  difficult,  owing  to  the  size  of  the  mass,  its  adhesion  to  the  anterior 
wall  of  the  abdomen,  to  the  epiploon,  and  to  the  peritoneum,  and  also  to  adhe- 


594 


Progress  of  the  Medical  Sciences. 


[April 


sions  with  the  ascending  colon  and  the  small  intestine.  Isolation  of  the  tumor 
was  effected  with  difficulty,  it  being  necessary  to  form  a  pedicle  with  the  uterus 
hypertrophied.  M.  Terrier  at  this  juncture  resorted  to  a  classic  proceeding,  viz., 
the  introduction  of  two  large  trocars,  to  supply  the  place  of  needles,  and  the 
application  of  two  iron- wire  handles  joined  by  Cintrat's  apparatus.  A  point  in  the 
operation,  worthy  of  special  attention,  was  the  fear  that  the  right  ureter  had  been 
included  in  the  wire  ligatures,  and  the  precaution  was  taken  to  isolate  the  vessels 
supposed  to  contain  the  ureter,  and  to  bring  them  out  through  the  abdominal  wound, 
so  that  the  urine  might  easily  flow  out,  and  the  performance  of  a  subsequent  ne- 
phrotomy was  avoided.  Happily,  however,  as  examination  afterwards  showed,  a 
hypertrophied  Fallopian  tube  was  only  involved.  As  was  thought,  the  tumor  was 
fibro-cystic,  weighing  about  97  pounds,  and  in  addition  containing  nearly  seven 
pints  of  fluid.  The  immediate  results  of  the  operation  were  uncomplicated  during 
the  first  fifteen  days.  All  the  sutures,  needles,  etc.,  were  removed  the  twelfth  day, 
and  the  temperature  was  below  100.4°  F.  The  fifteenth  day  febrile  symptoms 
appeared,  and  the  twenty-first  day  the  thermometer  reached  104°  F.  Abdominal 
pains  appeared,  and  shortly  a  discharge  composed  of  urine  and  considerable  pus 
flowed  from  the  pedicle.  Later  diarrhoea  and  vomiting  appeared.  A  little  more 
than  a  month  after  the  operation  the  local  and  general  symptoms  were  improved  ; 
nevertheless  there  appeared  at  the  level  of  the  wound  shreds  or  rather  dark- 
colored  soft  masses,  formed  by  gangrenous  cellular  tissue,  and  filled  with  white 
globules,  masses  which  were  gradually  eliminated  by  purulent  secretion.  The 
origin 'of  the  sphacelous  masses  was  difficult  to  determine  ;  nevertheless,  it  appeared 
probable  that  they  originated  in  the  perivesical  cellular  tissue,  perhaps  even  in 
portions  of  the  bladder. 

Towards  the  end  of  1883  the  patient  had  so  far  improved  as  to  be  able  to  sit 
up.  Relapse,  however,  occurred  in  January,  1884,  fever  again  appearing,  com- 
plicated with  epigastric  pain  and  vomiting  These  symptoms  improved  on  the 
occurrence  of  abundant  suppuration  of  the  pedicle,  but  again  in  February  sud- 
denly reappeared,  and  in  the  right  side,  in  the  region  of  the  kidney,  a  large  and 
painful  swelling  was  discovered,  which  was  evidently  the  cause  of  the  febrile 
manifestations.  The  cautery  was  twice  applied  over  the  swelling,  but  without 
effect.  Moreover,  the  tumor  in  the  side  appeared  to  communicate  with  the  wound 
of  the  pedicle,  and  from  compression  caused  the  exit  of  pus  in  great  quantities 
therefrom.  After  several  attempts  a  bougie  was  introduced  into  the  fistula,  and 
afterwards  a  probe  of  red  caoutchouc,  from  5  to  10  inches  in  length,  and  injections 
were  made  into  the  perirenal  region.  From  this  time  the  temperature  fell  to 
98.6°  F.  Twice  in  April,  however,  it  rose  to  104°  F.,  but  at  these  times  the 
probe  had  been  removed,  and  improperly  introduced.  After  the  introduction  of 
the  probe  the  cauterized  spots  were  allowed  to  heal,  and  antiseptic  injections,  at 
first  of  corrosive  sublimate  (1  to  1000),  and  afterwards  of  chloral  (1  to  100)  were 
made.  Finally,  the  injections  having  become  painful  they  were  omitted,  and 
the  probe  itself  daily  cleansed  in  an  antiseptic  solution  of  chloral.  The  patient 
still  retains  the  probe,  though  but  little  pus  issues  from  the  fistula,  and  her  health 
is  excellent.  How  long  the  probe  shall  be  used  is  a  point  undecided  by  expe- 
rience;  but  M.  Ferrier  gives  as  his  opinion  that  its  use  should  be  continued  so 
long  as  tolerated  by  the  tissues. — Archives  de  Tocologie,  Jan.  1885. 

Extirpation  of  the  Uterus. 
At  a  recent  meeting  of  the  Obstetrical  Society  of  London,  Dr.  W.  A.  Dun- 
can read  a  paper  on  Extirpation  of  the  Uterus.    The  author,  having  had  two 
cases  of  vaginal  extirpation,  proposes  to  give  details  of  them,  and  then  to  discuss 
the  whole  subject  of  extirpation  in  its  various  aspects. 


1885.] 


Midwifery  and  Gynaecology. 


595 


Case  1. — The  patient,  aged  thirty-seven,  married,  one  child  eleven  years  old, 
was  admitted  to  the  Royal  Hospital  for  Women  and  Children  on  December  11, 
1883,  with  a  slight  attack  of  pelvic  cellulitis.  When  seen  a  few  days  previously, 
there  was  found  a  small  growth  of  epithelioma  on  the  portio  vaginalis  near  the  os 
uteri,  and  only  involving  the  anterior  tip  of  the  cervix.  The  attack  of  cellulitis 
passed  away  gradually,  and  on  January  22,  1884,  extirpation  was  performed  per 
vaginam  according  to  Schroeder's  method;  great  difficulty  was  experienced  in 
ligating  the  broad  ligaments,  which  were  shortened  from  the  inflammatory 
thickening  left ;  the  double  drainage  tube  was  inserted,  and  iodoform  plugs  in  the 
vagina.  The  patient  made  an  uninterrupted  recovery,  and  was  discharged  cured 
on  the  thirty-ninth  day,  with  an  arched  cicatrix  in  the  vagina,  but  no  induration 
whatever.  She  was  readmitted  on  June  14th  (five  months  after  operation)  with 
cough,  pain  over  the  lower  ribs  on  the  right  side,  night-sweats,  and  pyrexia.  On 
the  25th  an  indurated  mass  was  felt  on  vaginal  examination  above  its  roof ;  pel- 
vic glands  enlarged.  The  patient  continued  in  much  the  same  state,  with  inter- 
mitting pyrexia,  the  temperature  remaining,  as  a  rule,  between  100°  and  105°; 
she  was  discharged,  at  her  own  request,  on  July  16th,  and  died  at  home  on 
November  1st. 

Case  2. — Mrs.  P.,  aged  fifty-four,  admitted  on  February  4th,  1884,  with  ulce- 
rating epithelium  of  cervix.  Married  thirty-two  years,  eight  children.  Quite 
well  from  menopause  (ten  years  ago)  until  eight  months  before  admission,  when 
hemorrhage  followed  coitus.  Vaginal  extirpation  on  February  26th,  as  in  Case 
1.  Collapse  set  in  as  soon  as  the  peritoneal  cavity  was  opened,  and  death  took 
place  twelve  hours  after  operation. 

The  author,  having  discussed  the  advantages  and  disadvantages  of  the  abdomi- 
nal and  vaginal  methods,  gave  statistics  of  all  the  cases  he  could  find,  showing 
that  after  137  abdominal  extirpations  there  were  38  recoveries  and  99  deaths, 
being  a  death-rate  of  72  per  cent.  ;  whilst  after  276  vaginal  extirpations  there  were 
197  recoveries  and  79  deaths,  being  a  death-rate  of  28.6  per  cent.  The  details 
of  the  after-treatment  were  then  discussed,  the  author  being  of  opinion  that  there 
was  no  necessity  either  to  sew  up  the  wound  in  the  vagina,  to  put  in  a  drainage- 
tube,  or  to  plug  the  vagina ;  but  he  insisted  on  the  importance  of  the  free  use  of 
iodoform  locally,  of  the  upright  posture  for  the  first  ten  days,  and  of  the  free 
administration  of  opium.  He  next  reviewed  the  various  malignant  and  non- 
malignant  diseases  for  which  the  operation  has  been  done,  and  was  of  opinion 
that  in  none  of  the  latter  was  it  ever  justifiable  ;  that  in  sarcoma  and  carcinoma 
of  the  body  of  the  womb  and  mucous  membrane  of  the  cervical  canal  it  was  indi- 
cated ;  whereas  in  cancer  of  the  portio  vaginalis,  for  which  it  has  frequently  been 
performed,  the  death-rate  is  four  times  greater  than  after  supra- vaginal  amputa- 
tion of  the  cervix,  and  the  ultimate  results  are  almost  precisely  alike  (32  per  cent, 
being  free  from  recurrence  two  years  later).  Hence  in  these  cases  he  argues  that 
we  are  not  justified  in  performing  it. 

Dr.  Braxton  Hicks  offered  a  word  of  caution  in  regard  to  accepting  the 
evidence  of  the  curette  in  cases  occurring  in  the  child-bearing  period  of  life, 
since  the  mucous  membrane  of  the  uterus  under  the  influence  of  pregnancy  and 
other  stimulants  presents  an  appearance  much  like  that  of  malignant  disease. 
Again,  sarcomatous  polypi  which  may  return,  and  ultimately  cease,  cannot  be 
distinguished  by  the  microscope  from  truly  malignant  growths. 

Dr.  John  Williams  thought  our  knowledge  of  the  operation  was  sufficient  to 
enable  us  to  form  a  judgment,  at  least  as  regards  the  vaginal  and  abdominal 
methods.  The  abdominal  method  is  far  the  more  fatal  (72  per  cent.),  and  is  as 
likely  to  be  followed  by  recurrence  as  the  other ;  it  has  therefore  practically 
been  discarded.    After  the  vaginal  method  the  mortality  is  from  25  to  34  per 


596 


Progress  of  the  Medical  Sciences. 


[April 


cent.  ;  the  author  estimated  it  at  28  per  cent.,  which  is  little  above  the  mortality 
of  ovariotomy  for  many  years  after  it  had  become  a  recognized  operation,  and 
this  mortality  might  be  considerably  reduced.  But  the  two  operations  are  very 
different.  If  the  patient  recovers  from  ovariotomy,  she  is  restored  to  health  and 
strength,  and  so  remains.  After  extirpation  of  the  uterus  for  cancer,  however, 
the  disease  recurs  in  a  large  number  of  eases  within  six  months,  while  very  few 
remain  free  after  two  years,  and  only  one  has  remained  free  for  five  years.  Again, 
most  of  these  cases  are  those  of  cancer  of  the  cervix,  and  not  of  the  body,  and 
supra-vaginal  amputation  gives  better  results  than  extirpation.  This  clearly  limits 
the  operation  to  cancer  of  the  body.  The  diagnosis  of  this,  however,  presents 
difficulties.  Dr.  Williams  has  done  the  operation  four  times,  and  the  only  patient 
who  recovered  from  it  died  a  month  later  of  fecal  fistula  high  up  in  the  small 
intestine.  The  patient  had  been  examined  under  ether,  and  the  uterus  was  found 
freely  movable,  very  slightly  enlarged,  and  no  growth  could  be  discovered  in  the 
pelvis,  nor  any  adhesions  between  the  uterus  and  surrounding  organs  ;  but  at  the 
operation  a  soft  adhesion  was  found  between  the  fundus  and  a  coil  of  intestine. 
The  disease  had  passed  through  the  uterine  wall  to  the  small  intestine,  and  three 
or  four  days  after  the  operation  liquid  feces  passed  by  the  vagina.  Here  the  most 
careful  examination  failed  to  discover  the  extension  of  the  disease  beyond  the 
uterus.  Again,  before  a  just  opinion  of  extirpation  can  be  formed  the  course  and 
history  of  cancer  of  the  body  must  be  better  known.  This  disease  is  far  com- 
moner than  was  formerly  supposed,  and  its  course  is  longer  than  was  believed. 
In  the  early  stages  of  cancer  the  pain  is  not  severe,  but  becomes  so  after  the  disease 
has  invaded  the  deeper  tissues.  Now,  when  recurrence  takes  place  after  operation, 
the  disease  is  placed  at  an  enormous  advantage  ;  it  recurs  at  the  edge  of  the  cica- 
trix, and  at  once  attacks  the  deeper  tissues,  being  associated  with  the  severe  suf- 
fering of  an  advanced  stage  of  cancer.  This  means  that  after  the  operation  the 
patient  has  a  few  weeks  or  months  of  comfort  and  supposed  freedom  from  disease  ; 
and  then  the  disease  returns  and  occupies  the  position  it  would  have  occupied, 
after  months  of  comparatively  little  suffering,  had  it  followed  its  course  unmo- 
lested, for  the  tissues  through  which  it  would  have  had  to  make  its  way  had  been 
removed  by  the  surgeon's  knife. 

Mr.  Thornton  expressed  his  agreement  with  the  conclusions  of  Dr.  W.  Dun- 
can, and  also  with  the  remarks  of  Dr.  Williams.  He  was  not  an  opponent  of 
operations  for  cancer  ;  in  the  case  of  the  breast  it  is  possible  to  remove  the  whole 
disease  and  all  suspicious  glands.  The  surroundings  of  the  uterus,  however,  were 
very  favorable  for  the  spread  of  cancer  beyond  the  possibility  of  complete  re- 
moval. He  thought  the  attack  of  cellulitis  in  Dr.  Duncan's  case  was  very  likely  due 
to  displacement  of  cancerous  elements  during  examination,  and  might  account  for 
the  rapid  recurrence  after  an  apparently  successful  operation.  Here -he  must  ex- 
press his  dissent  from  the  author ;  he  believed  the  practice  of  curetting  cancer  of 
the  uterus  to  be  very  dangerous  and  apt  to  spread  the  disease.  He  had  thought 
that  the  one  possible  indication  for  the  operation  was  severe  pain,  but  after  Dr. 
Williams's  remarks  he  was  inclined  to  alter  his  opinion.  Cancer  of  the  body  is 
slow  in  growth,  and  he  thought  it  was  rarely  painful  as  long  as  it  was  confined  to 
the  body.  The  fetor  of  the  discharge  might  be  controlled  by  insufflation  of  iodo- 
form. In  cancer  of  the  cervix  extirpation  was  inferior  to  amputation  of  the  cer- 
vix and  the  application  of  chloride  of  zinc.  He  preferred  this  method  to  all 
others  on  account  of  the  power  which  chloride  of  zinc  appeared  to  possess  of  fol- 
lowing up  the  cancer  elements  and  destroying  them.  Dr.  W.  Duncan  had  omit- 
ted one  point,  namely,  the  necessarily  imperfect  removal  of  the  tube  by  the 
vaginal  method.  As  they  are  part  of  the  uterus,  any  operation  which  leaves 
them  behind  must  be  imperfect.    This  condemns  the  vaginal  method  as  com- 


1885.] 


Medical  Jurisprudence  and  Toxicology. 


597 


pletely  as  the  frightful  mortality  of  the  abdominal  method  condemns  that  opera- 
tion. 

Mr.  DoRAisr  believed  that  there  were  anatomical  reasons  against  the  extirpa- 
tion of  the  cancerous  uterus.  Mierzewsky  and  Lebec  had  shown  that  in  the 
connective  tissue  between  the  body  of  the  uterus  and  peritoneum  there  is  a  dense 
network  of  lymphatics,  whilst  two  wider  lymphatic  plexuses  form  a  collar  round 
the  uterine  and  vaginal  portions  of  the  cervix.  The  lowest  of  these  communi- 
cates freely  with  the  vaginal  lymphatics.  All  these  networks  form  and  empty 
themselves  into  two  or  three  large  trunks  running  to  the  obturator  gland,  passing 
along  the  lower  border  of  the  broad  ligament.  He  had  felt  this  gland  soon  en- 
larged in  cases  of  cancer  of  the  cervix,  though  not  with  the  stony  hardness  like 
that  of  cancerous  axillary  glands,  except  in  advanced  cases,  where  the  uterus  was 
already  fixed  and  deeply  ulcerated.  This  disposition  of  the  lymphatics  favored 
the  spread  of  cancerous  elements,  and  the  whole  of  the  broad  ligaments  could 
not  be  removed. 

Dr.  Playfair  agreed  with  the  conclusions  expressed  in  the  paper.  In  the 
most  common  form  of  cancer  in  which  extirpation  was  most  likely  to  be  of  value 
the  diagnosis  was  uncertain  till  it  was  too  late  to  operate.  Apart  from  epithe- 
lioma, cancer  of  the  cervix  was  always  obscure  till  fixation  occurred,  which  dis- 
tinguished it  from  hyperplasia,  etc.  The  progress  of  the  disease  is  sometimes 
surprisingly  rapid.  In  one  case  seen  with  Mr.  Thornton,  one  week  sufficed  to  fix 
a  perfectly  mobile  uterus  and  to  veto  the  operation.  Even  in  cancer  of  the  body 
alone  he  was  doubtful  whether  extirpation  is  justifiable.  He  then  related  a  case  in 
which  he  had  suggested  extirpation  three  years  ago,  and  the  patient  is  still  alive 
in  comparative  comfort,  the  bleeding  having  been  controlled  by  insufflation  of 
iodoform  and  tannin.  In  epithelioma  of  the  cervix,  removal  of  the  diseased  tis- 
sue and  the  application  of  chloride  of  zinc  are  the  best  procedure.  He  related  a 
case  in  which  the  patient  remained  in  comparative  comfort  four  years  after  this 
operation,  though  the  disease  had  recurred.  He  related  a  case  in  which,  though 
the  case  was  well  adapted  for  extirpation,  he  had  advised  Sims's  operation.  The 
patient  went  to  Sir  Spencer  Wells,  who  had,  at  her  request,  extirpated  her  ute- 
rus. The  disease  recurred  within  a  year,  and  she  died.  He  had  no  doubt  Sir 
Spencer  Wells  would  acknowledge,  in  the  light  of  recent  experience,  that  if  the 
patient  had  been  let  alone  or  Sims's  operation  done,  her  expectancy  of  life  would 
have  been  as  good,  to  say  nothing  of  the  risks  of  the  operation. — Lancet,  January 
31,  1885. 


MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY. 

Ingestion  of  an  Enormous  Dose  of  Sulphate  of  Strychnine  ivithout  producing 

Toxic  Symptoms. 

Dr.  Lardier,  in  the  Gazette  Hebdomadaire  of  January  2,  1885,  gives  the 
history  of  a  case  of  a  patient  suffering  with  delirium  tremens,  in  which  he  admin- 
istered nearly  one  and  two-third  grains  of  the  sulphate  of  strychnia  in  twenty- 
three  hours.  He  first  employed  the  drug  in  delirium  tremens  in  1880,  and 
since  that  time  has  employed  it  habitually  for  this  condition,  always  with  com- 
plete success,  and  now  considers  the  remedy  a  specific  for  the  disease.  Dr.  Luton 
first  called  attention  to  the  action  of  the  drug  in  delirium  tremens,  and  Lardier, 
acting  upon  his  suggestions,  has  continued  the  use  of  the  remedy  with  marked 


598 


Progress  of  the  Medical  Sciences. 


[April 


success.  At  first,  the  drug  was  used  with  much  hesitancy,  but  experience  demon- 
strates that,  notwithstanding  its  powerful  effects,  it  can  be  used  without  danger  if 
closely  watched  during  its  administration. 

In  regard  to  the  apparently  enormous  dose  above  stated,  M.  Lardier  maintains 
that  no  substance  is  used  with  therapeutic  effect  in  disease  until  it  produces — all 
things  being  equal — results  similar  to  those  obtained  by  a  therapeutic  dose  in 
health. 

Though  the  quantity  of  the  drug  administered  in  the  case  under  consideration 
is  enormous,  no  possibility  of  error  exists.  The  preparation  was  prepared  by  a 
careful  and  reliable  pharmacist,  and  was  administered  by  the  wife  of  the  patient 
scrupulously  according  to  directions.    The  history  of  the  case  is  as  follows  :  — 

Patient  first  seen  December  4,  1884,  and  was  an  inveterate  drinker,  addicted 
especially  to  brandy,  and  showed  unmistakable  symptoms  of  delirium  tremens. 
The  strychnia  treatment  was  at  once  begun,  and  pills  of  strychnia  containing  aa 
y1^  gr.  On  the  4th  and  5th  of  December  a  pill  was  administered  every  two 
hours,  day  and  night.  The  morning  of  the  5th,  no  change  being  evident,  the 
same  dose  was  maintained,  and  in  addition  a  hypodermic  injection  of  T\  of  a  gr. 
was  given  in  the  evening  of  December  6th.  The  succeeding  night  was  passed 
absolutely  without  slumber,  hallucinations  persistent.  Profuse  sweat  and  red 
spots  were  noticeable  upon  the  forehead  and  upper  part  of  the  face. 

Two  men  could  with  great  difficulty  restrain  the  patient  at  this  time. 

The  dose  of  gr.  of  strychnia  produced  no  effect,  and  it  was  determined  to 
push  the  drug  to  the  point  of  its  manifesting  its  physiological  effect.  Accord- 
ingly, December  6,  from  12.30  P.  M.,  gr.  was  administered  every  hour.  In  the 
evening,  at  7.30,  the  wife  of  the  patient  reported  him  not  improved,  but  suffering 
cramps  in  the  legs,  and  stiffness  of  the  jaws.  The  pills  were  ordered  stopped  till 
the  following  morning;  but  at  8.30  M.  Lardier  was  hastily  called.  The  patient* 
in  attempting  to  walk,  had  fallen,  cut  his  head,  and  fractured  a  rib.  Contrary 
to  the  report  of  his  wife,  no  symptoms  of  strychnia  poisoning  existed.  The 
pulse  was  124,  and  the  body  drenched  with  sweat.  ^  gr.  of  strychnia  sulph. 
was  then  administered,  and  effect  carefully  looked  for,  but  was  not  manifested. 
Thirty  minutes  after  y1^  gr.  was  administered  by  the  mouth,  in  the  presence  of 
M.  Lardier.  The  following  night  was  passed  without  sleep,  the  patient  being  still 
delirious.  l5  grain  strychnia  administered  every  hour.  December  7,  at  6  A.  M., 
the  patient's  pulse  was  90  ;  he  was  calmer,  and  answered  questions  intelligently 
if  addressed  authoritatively.  At  6  A.  M.  of  this  day  sixteen  of  the  twenty  pills 
contained  in  the  last  box  had  been  taken  by  the  patient,  the  last  one  being  admin- 
istered by  M.  Lardier  himself.  From  this  time  ^  gr.  was  given  every  half  hour 
for  eleven  and  one-half  hours.  In  twenty-three  hours  1T9^  grs.  were  administered 
by  the  mouth,  and  ^  gr.  hypodermically.  The  same  pills  were  continued  every 
half  hour  until  3  P.  M.,  when  the  patient  requested  food.  At  4  P.  M.  he  no 
longer  trembled,  his  gait  was  steady  ;  movement  active,  but  unfaltering.  Finally, 
he  became  exhausted,  and  being  put  to  bed,  made  no  effort  to  rise.  He  rested 
some  time ;  during  sleep,  however,  there  was  a  little  restlessness,  and  some  inco- 
ordination of  movement,  which  at  length  disappeared,  and  the  night  was  passed 
quietly. 

At  8  A.  M.  the  patient  awoke,  requested  food,  and  again  went  to  sleep.  At  1 
P.  M.  he  again  awoke,  his  mind  being  entirely  clear.  At  4  P.  M.  the  pulse  was 
75,  and  there  existed  slight  moisture  of  the  skin.  The  patient  remembered 
nothing  that  occurred  during  his  attack.  Tremor  had  entirely  disappeared,  and 
not  the  least  symptom  of  strychnia  poisoning  was  evident.  December  8,  ban- 
dages applied  to  the  broken  rib  ;  with  the  exception  of  the  pain  due  to  this 
cause,  the  patient  was  entirely  well. 


1885.] 


599 


INDEX. 


A. 

Abbott,  malarial  fever,  416 

Acid,  carbolic,  in  typhoid  fever,  568 

Adams,  spontaneous  dislocation  of  femur, 

treatment  of,  281. 
Adults,  anterior  poliomyelitis  in,  138 
Albuminuria,  pathology  and  clinical  sig- 
nificance, 216. 
Alexander,  Adams's  operation  for  shorten- 
ing the  round  ligament,  293 
Allen,  Human  Anatomy,  review  of,  228 
Alt,  Ophthalmology,  review  of,  212 
Amaurosis,  due  to  anaesthesia  of  the  optic 

nerve,  588 
Anaemia,  pernicious,  253,  482 
Anatomy,  Allen's  review  of,  228 
Aneurism,  popliteal,  simulating  sarcoma, 
52 

—  simultaneous  double  distal  li- 
gation of  carotid  and  subclavian  arteries 
for,  584 

Antipyrin,  561 

Anuria,  from  occlusion  of  ureters,  575 

Aorta,  Diseases  of  Thoracic,  Bramwell,  re- 
view of,  196 

Apostoli,  double  or  bipolar  uterine  faradi- 
zation, 250 

Aspiration,  a  plea  for  cardiac,  79 

B. 

Bacteria,  Magnin  and  Sternberg  on,  review 
of,  238 

Baldi,  researches  on  the  biliary  secretion, 
245  » 

Balleray,  erysipelas  as  a  complication  of 

pregnancy  and  labor  ;  herniotomy  during 

erysipelas,  160 
Bar  well,  ligature  of  carotid  and  subclavian 

arteries  for  aneurism,  584 
Belfield,  Diseases  of  the  Urinary  and  Male 

Sexual  Organs,  review  of,  542 
Bennett,  electro-therapeutics,  251 
Biliary  secretion,  241 

Billings,  Ventilation  and  Heating,  review 
of,  190 

Bischoff,  occlusion  of  ureters,  575 
Bladder,  diverticulum  of,  in  woman,  289 

 ,  intraperitoneal  rupture  of,  583 

 ,  Tumors  of,  Thompson  on,  review 

of,  202 

Blood,  examination  of.  in  acute  diseases, 
252 

 ,  modification  of  during  pregnancy, 

246 


Bourneville,Epilepsy, Hysteria, and  Idiocy, 

review  of,  226 
Brain,  bony  tumor  of,  259 

 ,  lodgment  of  a  breech-pin  in,  128 

 ,  Topography  of,  review  of,  536 

Bramwell,  Diseases  of  the  Heart  and  Aorta, 

review  of,  196 
Bristowe,  Practice  of  Medicine,  review  of, 

181 

Broad  Ligament,  Tumors  of,  Doran,  re- 
view of,  186 

Bruns,  resection  of  knee,  281 

Buckham,  Medico-legal  Relations  of  In- 
sanity, review  of,  206 

Bull,  The  Ophthalmoscope  and  Lues,  re- 
view of,  550 

C. 

Caecum,  excision  of,  for  epithelioma,  580 
Cancer  of  the  tongue,  577 
I  Cathartics,  experimental  investigation  on 

the  action  of  saline,  241 
Ceci,  etiology  of  cholera,  564 
Chancres,   soft  treatment  by  iodoform, 

279 

Charles,  Elements  of  Physiological  and 
Pathological  Chemistry,  review  of, 233 

Chemistry,  Physiological  and  Patho  logi- 
cal, Charles,  review  of,  233 

Cholera,  etiology  of,  564 

 ,  intraperitoneal  styptic  and  seda- 
tive injection  in,  567 

 ,  treatment  of,  565 

Claiborne,  hiatus  in  fauces,  with  congeni- 
tal absence  of  the  tonsils,  490 

Cocaine,  as  an  anaesthetic  in  ophthalmic 
practice,  283. 

 ,  cerebral  symptoms  from  hypoder- 
mic injections  of,  562 

 ,  hydrochlorate  in  obstetrics,  562 

Cochlea,  exfoliation  of,  without  loss  of 
hearing,  589 

Color-perception,  a  correlation  theory  of, 
98,  462 

Congestion,  peculiar  pulmonary,  79 
Contusion  of  intestines,  272 
Corre,  Fevers  of  Hot  Climates,  review  of, 
221 

Corrosive  sublimate  in  obstetrics,  591 
Councilman,  malarial  fever,  416 

 ,  production  of  tuberculosis 

by  inoculation,  17 
Craniotomy,  286 
1  Croup,  membranous,  317 


600 


Ind 


EX. 


[April 


D. 

Davis,  Practice  of  Medicine,  review  of,  175 

Deaf-mutism,  caused  by  auricular  com- 
pression, treatment  of,  589 

Delirium  tremens,  treatment  of  with  sul- 
phate of  strychnine,  597 

Dermatitis  herpetiformis  caused  by  nerv- 
ous shock, 94 

Dickey,  congenital  ectropia  lentis,  492 

Diphtheria,  255 

Dislocation,  spontaneous,  of  femur,  treat- 
ment of,  281 

Doran,  Tumors  of  the  Ovary,  Fallopian 
Tube,  and  Broad  Ligament,  review  of, 
186 

Drummond,  on  Diseases  of  Brain  and 
Spinal  Cord,  review  of,  240 

Duhring,  dermatitis  herpetiformis  caused 
by  nervous  shock,  94 

Dujardin-Beaumetz,  gastro-intestiDal  the- 
rapeutics, 246 

Duncan,  extirpation  of.uterus,  594 

Duodenostomy,  363 

Dysentery,  chronic,  treatment  of,  265 

E. 

Ectasia,  urethral,  289 

Ectropia  lentis,  congenital,  491 

Electricity,  therapeutic  effect  of,  and  elec- 
tro-diagnostic exploration  of  the  visual 
field,  248 

Electro-therapeutics,  251 

Eliot,  anterior  poliomyelitis  in  adults,  138 

Engelskjon,  electricity  in  diagnostic  explo- 
ration of  the  visual  field,  24S 

Epilepsy,  Bourneville  on,  review  of,  226 

 ,  Jacksonian,  31 

Epithelioma,  163 

 ,  uterine,  and  nephritis,  573 

Erysipelas,  as  a  complication  of  pregnancy 
and  labor,- 160 

 ,  herniotomy  in,  160 

Euphorbia,  pelulifera,  563 
Exophthalmos,  one  sided,  transitory,  486 

F. 

Fallopian  Tube,  Tumors  of,  Doran  on,  re- 
view of,  186 
Fauces,  hiatus  in  anterior  pillar  of,  490 
Fever,  cold  water  treatment  of,  254 

 ,  malarial,  pathology  of,  416 

Fevers  of  Hot  Climates,  Corre  on,  review 
of,  221 

Fish,  external  pistol-shot  wounds,  297 
Fistulas,  in testino- vaginal,  388 

 ,  urethral,  treatment  of,  583 

Fry,  fistulas,  intestino-vaginal,  388 
Fiirst,  retroperitoneal  hernia,  276 

G. 

Gastrectomy,  363 
Gastroenterostomy,  359 
Gasti-o-intestinal  therapeutics,  246 
Gastrostomy,  363 

Glaucoma,  Chronic,  Treatment  of,  review 
of,  539 

Gleitsmann,  laryngeal  hemorrhage,  396 
Godson,  Porro's  operation,  500 
Gonorrhoeal  disease  of  uterine  appendages, 
295 

Gout,  treatment  of,  with  iodoform,  570 


Gowers,  on  Diseases  of  the  Spinal  Cord, 
review  of,  218 

H. 

Hematocele,  retro-uterine,  treatment  of, 
290 

Hamilton,  introspective  insanity,  130 
 ,  Treatise  on  Fractures  and  Dis- 
locations, review  of,  553 
Harrison,  the  after-treatment  of  lithotomy, 
278 

Hartmann,  chiselling  of  the  mastoid  pro- 
'   cess,  284 

Hartridge,  The  Refraction  of  the  Eye,  re- 
view of,  242 

Hay,  Experimental  Investigation  of  the 
Physiological  Action  of  the  Saline  Cath- 
artics, review  of,  241 

Hay  em,  examination  of  the  blood  in  acute 
diseases,  252 

Heart,  aspiration  of,  79 

 ,  wounds  of,  268 

Heath,  Injuries  and  Diseases  of  the  Jaw, 
review  of,  554 

Heating  and  Ventilation,  Billings  on.  re- 
view of,  190 

Hemiplegia,  double  infantile  spastic,  58 

Hemorrhage,  laryngeal,  396 

 ,  post-partum,  prophylaxis  of, 

592 

 ,  treatment  of, 

by  hot  uterine  douches,  288 

Hermaphroditism,  557 

Hernia,  retroperitoneal  due  to  arrest  of 
intestinal  development,  276 

Herniotomy,  operation  for,  during  exist- 
ence of  erysipelas,  160 

Hiccough,  treatment  with  jaborandi,  571 

Hinsdale,  pernicious  ansemia,  482 

Holmes,  extirpation  of  the  larynx,  266 

Hospitals  for  the  treatment  of  acute  in- 
sanity, intermediate,  38  . 

Hun,  alcoholic  paralysis,  372 

Hypnotism,  557 

Hypoglossal  nerve,  regeneration  of,  146 
Hysterectomy,  593 

I. 

Idiocy,  Bourneville  on,  review  of,  226 
Inoculation,  production  of  tuberculosis  by, 
17 

Insanity,  acute,  treatment  of,  38 

 -,  introspective,  130 

 -,  Medico-legal  Relations  of,  Buck- 
ham  on,  review  of,  236 
Intestine,  excision  of,  274 

 ,  rupture  and  contusions  of,  272 

Iodoform,  treatment  of  gout  by,  570 
 soft  chancres,  279 

J. 

Jaborandi,  treatment  of  hiccough  with,  571 

Jackson,  retinoscopy,  404 

Johnson,  treatment  of  chronic  glaucoma, 

539 

K. 

Kemper,  lodgment  of  a  breech-pin  in  the 
brain,  128 

 ,  spontaneous  rupture  of  mem- 
branes, 412 


1885.] 


Index. 


601 


Keetley,  treatment  of  osteomyelitis.  5S6 

Klebs,  etiology  of  cholera.  564 

Knapp,  cutaneous  and  deep  reflexes,  429 


Labor  complicated  with  erysipelas,  160 

Labyrinth,  hypodermic  injections  of  pilo- 
carpi in  affections  of,  5SS 

Laparo-elytrotomy,  successful  case  of,  591 

Lardier,  treatment  of  delirium  tremens 
with  sulphate  of  strychnine^  597 

Laryngo-typhus,  368 

Larynx,  extirpation  of,  266 

 .  hemorrhage  of.  396 

Leuf,  a  peculiar  form  of  pulmonary  con- 
gestion. 79 

Levden.  sclerosis  of  the  coronary  arteries, 
263 

Litholapaxy.  5  SI 

Lithotomy,  after-treatment  of,  27S 
Locomotor  ataxia,  ocular  affection  in,  587 

M. 

Mastoid  process,  chiselling  of,  283 
McNutt,  double  infantile  spastic  hemi- 
plegia, 58 
Medication,  intra-uterine,  292. 
Membranes,  spontaneous  rupture  of,  112 
Muscles,  electro-excitability  of,  560 
Myotomy,  291 

N. 

Naunyn.  nature  of  fever.  254 

Nephrectomy,  for  calculous  pyelitis,  272 

—  .  lumbar,  269 

Nephritis,  and  uterine  epithelioma,  573 

Nerves,  regeneration  of  the  vagus  and  hy- 
poglossal, 146 

New  .T  -rsev  State  Board  of  Health,  review 
of.  521 

 Tork  State  Board  of  Health,  review 

of,  523 

Nitrate  of  silver,  enemata  of,  in  chronic 
dysentery,  265 

O. 

(Esophagus,  malignant  stricture  of,  57S 

 .  varices  of.  260 

Oliver,  a  correlation  theory  of  color-per- 
ception, 98,  462 

Omentum,  prolaDse  of,  throuah  rectum, 
275 

Optic  nerve,  amaurosis  due  to  anaesthesia 
of,  5S8 

Osier.  Jaoksonian  epilepsy,  31 
Osteomyelitis,  treatment  of,  586 
Ovariotomy,  with  suture  of  base  of  tumor 

into  the  abdominal  wound,  294 
 in  Italv.  review  of.  541 


Pilocarpin,  hypodermic  injection  of,  in  af- 
fections of  the  labyrinth,  58S 
Pistol-shot  wounds,  external,  297 
Playfair,  extirpation  of  uterus,  597 
Pneumonia,  infectious  and  parasitic,  261 
Poliomyelitis,  anterior,  in  adults,  13S 
Politzer,  hypodermic  injection  oif  pilocar- 
pine in  affections  of  the  labyrinth,  588 
Polvarthritis,  acute  rheumatic,  infantile. 
569 

Poore,  osteotomy  and  asteoclasis  for  de- 
formities of  the  lower  extremities,  210 
Porro-Caesarean  statistics,  500 
Porro's  operation.  500 
Pregnancy  and  labor  complicated  with 

erysipelas,  160 
Prolapse  of  omentum,  275 
Psoriasis,  verruca,  epithelioma,  163 
Pyelitis,  nephrectomy  for,  2T2 
Pylorectomy,  318 

partial,  369 


Ovary,  tumors  of,  1S6 


Pancreatitis,  acute,  in  childbed,  264 
Paralysis,  alcoholic,  372 
Peptonuria,  265 

Perineum ,  prevention  of  rupture  of,  by 

unilateral  incisions,  287 
Peritonitis,  spontaneous,  572 
Peruzzi,  The  Fifth  Hundred  Ovariotomies 

in  Italy,  review  of,  541 
Phosphorus  in  tubercular  disease,  257 


Pylorus,  digital  divulsion  of,  364 
R. 

Reviews — 

Allen,  Human  Anatomy,  228 
Alt.  A  Treatise  on  Ophthalmolosrv, 
243 

Ashhurst,  International  Encyclopaedia 

of  Surgery,  vols.  iv.  and  v.,  526 
Belfield,  Diseases  of  the  ITrinary  and 

Male  Sexual  Organs,  542 
Billings,  Ventilation  and  Heating,  190 
Bourneville,  Researches  upon  "  Ep: 

lepsy.  Hysteria,  and  Idiocy,  226 
Bramwell.  Diseases  of  the  Heart  and 

Aorta,  196 
Bristowe,  Practice  of  Medicine,  181 
Buckham,  Insanity,  206 
Bull,  The  Ophthalmoscope  and  Lues, 

550 

Carter,  Elements  of  Practical  Medi- 
cine, 244 

Charles,  Physiological  and  Pathologi- 
cal Chemistry,  233 
Corre,  Fevers  oYHot  Climates.  221 
Dalton,  Topography  of  the  Brain,  526 
Davis,  Practice  of  Medicine,  175 
Doran,  Tumors  of  the  Ovary,  Fallo- 
pian Tube,  and  Broad  Ligament, 
186 

Drummond.  Brain  and  Spinal  Cord, 
210 

Emmet,  Gynaecology,  193 

Godson,  Truzzi,  Latest  Porro-Caesa- 

rean  Statistics,  500 
Gowers.  On  Diseases  of  the  Spinal 

Cord.  218 

Hamilton,  Fractures  aud  Dislocations, 
553 

Hartridcre,  Refraction  of  the  Eye,  242 
Hav.  Phvsiolotjical  Action  of  Saline 

Cathartics,  211 
Heath,  Injuries  and  Diseases  of  the 

Jaws,  554 
Index-Catalogue  of  the  Library  of  the 

Surgeon-General's  Office.  230 
Johnson,  New   Method  of  Treating 

Chronic  Glaucoma,  539 
 -.   Testing   for   Albumen  and 

Susrar,  213 


602 


Index. 


[April 


Reviews — 

Loomis,  Practice  of  Medicine,  179 
Magnin  and  Sternberg,  Bacteria,  238 
Milton,  On  Pathology  and  Treatment  1 

of  Gonorrhoea,  224 
Oliver,  On  Bedside  Urine  Testing, 

215 

Peruzzi,  The  Fifth  Hundred  Ovarioto- 
mies in  Italy,  541 

Poore,  Osteotomy  and  Osteoclasis,  210 

Ralfe,  Clinical  Chemistry,  231 

Reeves,  Bodily  Deformities  and  their 
Treatment,  517 

Regeneration,  of  the  Vagus  and  Hypo- 
glossal Nerves,  146 

Reichert,  Regeneration  of  the  Vagus 
and  Hypoglossal  Nerves,  146 

Rindfleisch,  Elements  of  Pathology, 
234 

Rohe,  Text-Book  of  Hygiene,  516 
Rosenbach,  Musical  Heart  Murmurs, 
234 

Smith,  Diseases  of  Children,  504 
 ,  Report  of  the  Commissioner  of 

Lunacy  of  the  State  of  New  York, 

510 

Sternberg,  Malaria  and  Malarial  Dis- 
eases, 182 

Stille  and  Maisch,  National  Dispensa- 
tory, 219 

Thompson,  Surgery  of  Urinary  Or- 
gans, 544 

■  ,  Tumors  of  the  Bladder, 

202 

Tosswill,  Diseases  and  Injuries  of  the 

Eye  and  Eyelids,  243 
Van  Buren,  Lectures  on  the  Princi- 
ples of  Surgery,  538 
Reeves,  Bodily  Deformities,  review  of, 
517 

Reflexes,  cutaneous  and  deep,  429 
 ,  tendon,  560 

Refraction,  measurement  of,  by  shadow 
test,  404 

Reichenbach,  incised  wound  of  stomach, 
579 

Retinoscopy,  404 

Rheumatism,   pulmonary  manifestations 
in,  570 

Richardson,  treatment  of  cholera,  567 

Rickets,  anatomical  origin  of,  256 

Robin,  treatment  of  typhoid  fever  with 

carbolic  acid,  568 
Robins,  writers'  cramp  and  its  treatment, 

452 

Rohe,  Text-book  of  Hygiene,  review  of, 
516 


Sanger,  treatment  of  gonorrheal  disease  of 

the  uterine  appendages,  295 
Santesson,  urethral  ectasia,  289 
Sarcoma,  simulation  of  aneurism  by,  52 
Sattler,  one-sided  ophthalmos,  486 
Sclerosis  of  the  coronary  arteries,  263 
See,  infectious  and  parasitic  pneumonia,  j 

261 

Semmola,  treatment  of  cholera,  565 
Shepherd,  popliteal  aneurism  simulating  j 
sarcoma,  52 


Shock,    nervous,    producing  dermatitis 

herpetiformis,  94 
Skene,  laparo-elytrotomy,  591 
Smith,  membranous  croup,  317 
Spear,  partial  pylorectomy,  369 
Stenosis,  pyloric,  345 

Sternberg,  production  of  tuberculosis  by 

inoculation,  17 
Stomach,  wounds  of,  penetrating,  578,  579 
Strychnia,  enormous  dose  of,  597 
Supra-renal  capsule,  pathological  physiol- 
ogy of,  558 
Symphysis   pubis,  separation  of  during 
labor,  286 

T. 

Terrier,  hysterectomy,  593 
Thallin,  563 

Thompson,  Surgery  of  the  Urinary  Or- 
gans, review  of,  544 

,  tumors  of  the  bladder,  202 


Thornton,  extirpation  of  uterus,  596 
Tiling,  penetrating  wound  of  stomach,  578 
Tissoni,  pathological  physiology  of  the 

supra-renal  capsule,  558 
Tonsils,  congenital  absence  of,  490 
Transfusion  of  blood,  new  apparatus  for, 

563 

Truzzi,  Porro's  operation,  500 
Tubercular  disease,  treatment  of  by  phos- 
phorus, 259 
Tuberculosis,  inoculation  of,  571 

•,  production  of  by  inocula- 


tion, 17 

Typhoid  fever,  carbolic  acid  in,  568 
U. 

Ulcer,  perforating,  of  the  foot,  treatment 
of,  280 

tTmbilicus,  treatment  of  in  new-born,  593 
Ureters,  occlusion  of,  575 
Urethrocele,  vaginal,  289 
Urine,  new  methods  of  testing,  560 

 ,  on  bedside  testing  of,  Oliver,  review 

of,  215 

 ,  testing  of.  Johnson  on,  review  of, 

213 

Uterine  faradization,  250 
Uterus,  extirpation  of,  594 

V. 

Vagus,  regeneration  of  the,  146 

Van  Bibber,  hospitals  for  treatment  of 

acute  insanity,  38 
Van  Buren,  Principles  of  Surgery,  review 

of,  53S 

Varices  of  oesophagus,  260 

Verruca,  163 

Voisin,  hypnotism,  557 

W. 

White,  psorias — verruca — epithelioma,  163 
Whitehead,  excision  of  csecum  for  epithe- 
lioma, 580 
Winslow,  pyloric  stenosis,  345 
Wounds,  external  pistol-shot,  297 
Writers'  cramp,  452 


Ziemssen,  occlusion  of  ureters,  575 


1885.]     American  Journal  of  the  Medical  Sciences. 


603 


Bellevue  Hospital  Medical  College. 

Foot  of  East  Twenty-sixth  Street, 
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SPRING  SESSION,  1885. 


The  Spring  Session  of  1885  will  begin  on  Monday,  March  16th,  and 
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Examination  of  Urine,  Prof.  Janeway  ;  Surgical  Operations  on  the 
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the  Use  of  Instruments,  Surgical  Dressings,  etc.,  Profs.  Mott,  Bryant, 
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Demonstrations. 


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Lea  Brothers  &  Co.'s  Medical  and  Surgical  Publications. 

FLINT'S  PRACTICE  OF  MEDICINE. -Fifth  Edition,  with  Appendix. 
A  Treatise  on  the  Principles  and  Practice  of  Medicine.    Designwl  tor 

the  use  of  Students  and  Practitioners  of  Medicine.  With  an  Appendix  on  the  Researches  of 
Koch,  and  their  bearing  on  the  Etiology,  Pathology,  Diagnosis  and  Treatment  of  Phthisis. 
By  Austin  Flint,  M.D  ,  Professor  of  the  Principles  and  Practice  of  Med.  and  of  Clin.  Med. 
in  Bellevue  Hospital  Medical  College,  N.  Y.  Fifth  edition,  revised  and  largely  rewritten.  In 
one  large  octavo  volume  of  1160  pages.    Cloth,  $5.50  ;  leather,  $6.50  ;  half  Russia,  $7. 

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The  reader  will  meet  in  it  all  the  latest  words  on  ! 


BAKTHOLOW  ON  ELECTRICITY. — Second  Edition. 
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Boberts  Bartholow,  A.M.,  M.D.,  LL.D.,  Professor  of  Materia  Medica  and  General  Thera- 
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In  one  very  handsome  octavo  volume  of  292  pages,  with  109  illustrations.    Cloth,  $2  50. 

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appropriate  places  most  of  the  new  facts  and  appli-  English  language  moie  trustworthy  than  this  one. 
cations  of  electricity  to  medicine  that  have  been  It  contains  all  that  the  general  practitioner  or,  in- 
brought  forward  in  recent  years.  In  short,  the  deed,  the  expert  will  ever  pat  into  practice — Tne 
book  is  fully  up  to  the  times.  We  welcome,  as  an  Journal  of  Nervous  and  Mental  Disease,  Jan. 
important  feature,  the  full  treatment  given  to  the  1883. 
subject  of  electro  diagnosis.    We  may  safely  say 


CLOUSTON  ON  MENTAL  DISEASES. -With  an  Appendix. 

Clinical  Lectures  on  Mental  Diseases.    By  Thomas  S.  Cm>uston.  M.D  , 

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Appendix  containing  an  Abstract  of  the  Statutes  of  the  UniDed  States  and  of  the  several 
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separately  in  one  8vo.  volume  of  108  pp.    Cloth,  $1.50. 


The  descriptions  of  the  diseasesand  cases  are  sim- 
ple and  practical,  but  true,  and  one  sees  as  he  reads 
that  they  are  given  by  one  perfectly  familiar  from 
daily  observation  with  the  cases  and  diseases  he  is 
speaking  of.  One  feature  of  the  book  which  com- 
mends it  highly,  and  which  is  not  to  be  found  in 


any  other  work  on  mental  di  ease,  is  the  hints  and 
descriptions  given  as  to  the  practical  management 
and  care  of  the  cases.  We  can  heartily  recomnipnd 
it  to  the  student  a"d  busy  general  practitioner.— 
Archives  of  Medicine,  Jane,  1884. 


CHARLES'  PHYSIOLOGICAL  AND  PATHOLOGICAL  CHEMISTRY. 

The  Elements  of  Physiological  and  Pathological  Chemistry.  A  H find- 
book  for  Medical  Students  and  Practitioners.  Containing  a  General  Account  of  Nutrition, 
Foods  and  Digestion,  and  the  Chemistry  ot  the  Tissues  Organs,  Secretions  and  Excretions  of  the 
Body  in  Health  and  Disease.  Together  with  the  methods  for  preparing  or  separating  their  chief 
constituents  as  also  for  their  examinaoion  in  detail,  and  an  outline  Syllabus  of  a  Practical  Course 
of  Instruction  for  Students.  By  T.  L'ranstoun  Charles,  M.D.,  F.C.S.,M.S.,  Lecturer  on  Prac- 
tical Physiology,  St.  Thomas'  Hospital,  London  ;  Late  Medical  Registrar,  St.  Thomas'  Hospital ; 
and  formerly  Assistant  Professor  and  Demonstrator  of  Chemistry  and  Chemical  Physics,  Queen's 
College,  Belfast.  In  one  handsome  octavo  volume  of  463  pages,  with  38  woodcuts  and  one 
chromo-lithographic  plate.    Price,  in  cloth,  $3.50. 

Charles  has  devoted  much  space  to  the  elucidation 
of  urinary  mysteiies.  He  dees  this  with  much  de- 
tail and  yet  in  a  practical  and  intelligible  manner. 


Dr.  Charles  is  fully  impressed  with  the  importance 
and  practical  reach  of  his  subjec;,  and  he  has  treated 
it  in  a  competent  and  iustiuctive  manner.  We  can- 
not recommend  a  better  book  than  the  present.  Id 
fact,  it  fills  a  g  ip  in  medical  text-books,  and  that  is 
a  thing  which  can  rarely  be  said  nowadays  Dr. 


In  fact,  the  author  has  filled  his  book  with  many 
practical  hints. — Medical  Record,  Dec.  20,  1SS4. 


GROSS  0~N  DISORDERS  OP  THE  MALE  SEXUAL  ORGANS.— 
New  Edition— Just  Ready. 
A  Practical  Treatise  on  Impotence,  Sterility  and  Allied  Disorders  of 

the  Male  Sexual  Organs.  By  Samuel,  W.  Gross,  A.M.,  M.D.,  Professor  of  the  Principles  of 
Surgery  and  of  Clinical  Surgery  in  the  Jefferson  Mediral  College .  In  one  very  handsome 
octavo  volume  of  168  pages,  with  16  illustrations.    Cloth,  $1.50. 

hand  in  hand  with  his  experience.  In  regard  to  the 
various  organic  and  functional  di>orders  of  the  male 
generative  apparatus,  he  nas  had  exceptional  op- 
portunities for  obsei  vation,  and  Lis  book  sLows  that 


The  book  is  the  outcome  of  iiitelligent  clinical  ob- 
servation and  extensive  experience.  The  arrange- 
ment aod  classification  leave  nothing  to  be  desired 
in  the  way  of  c!earne-s;  and  practitioners  who  may 
be  called  upon  to  treat  these  cases  will  find  the 
directions  both  for  diagnosis  and  treatment  very 
perspicuous  and  sound. —  Liverpool  Medico-Ohirur- 
gicalJnurnal,  July,  1SS2 

The  author  of  this  monograph  is  a  man  of  positive 
convictions  and  vigorous  style.  This  is  justified  by 
his  experience  and  by  his  study,  which  has  gone 


he  has  not  neglected  to  compare  his  own  views  with 
thoi1,  of  other  authors.  The  result  is  a  work  wnieh 
can  be  safe  y  recommended  to  both  physicians  and 
surgeons  >.a  a  guioe  in  the  treatment  of  the  disturb- 
ances it  refers  to.  It  is  the  best  treatise  on  the  sub- 
ject with  which  we  are  acquainted. — The  Medical 
News,  Sept.  1,  18S3. 


LEA  BROTHERS  &  CO.,  Publishers,  Philadelphia. 


Date  Due 


SMITHSONIAN  INSTITUTION  LIBRARIES 


3  9088  01225  0106 


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